AMRPA Magazine February 2018 by AMRPA

February 2018 â&#x20AC;¢ Vol. 21, No. 2

PUTTING THE PATIENT AT THE CENTER OF CARE

Volume 21, Number 2

Contributors Richard Kathrins, PhD Chair, AMRPA Board of Directors, CEO, Bacharach Institute for Rehabilitation

Letter from the Chair........................................................................................... 3

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

CMS and OMHA Try to Limit the ALJ Backlog ................................................ 8

Peter Thomas, JD Counsel to the AMRPA Consumer and Clinical Affairs Committee, Principal, Powers Pyles Sutter & Verville, PC

What Is a PPS Coordinator Supposed To Do?................................................ 11

Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-Advanced Outcomes Design Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA

AMRPA Legislative Update................................................................................. 4

TRICARE Publishes Final Rule on Payment for IRFs and Long-term Care Hospitals ................................................................................ 13 MedPAC Issues Post-Acute Care Payment Recommendations for FY 2019 ........................................................ 15 CMS Announces New Voluntary Bundled Payment Model: BPCI Advanced .................................................................... 17

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

Office of the Actuary Releases 2016 National Health Expenditures ............ 20

Mimi Zhang Policy and Research Associate, AMRPA

AMRPA Responds to MedPACâ&#x20AC;&#x2122;s Draft Recommendation of Five Percent Reduction for IRFs ...................................................................... 21

Lovelyn Robinson Editorial and Research Assistant, AMRPA

AMRPA Kicks Off 2018 Federal Election Center............................................. 23 New Data Submission System Announced for Clinicians in the Quality Payment Program .................................................... 25 CMS Addresses Improper Discharges from Nursing Homes ...................... 26

AMRPA Magazine, Volume 21, Number 2. AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA). AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Individuals who are employees of member institutions may subscribe to the magazine for $100 annually. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th Street, NW, Washington, DC 20045 USA. Make checks payable to AMRPA.

CMS Issues Advance Notice on Proposed Changes to Medicare Advantage Risk Adjustment Model .......................................... 27 CMS Issues New IRF Coverage Requirement Documents; AMRPA Seeks Provider Feedback ................................................................... 28 Follow-Up Phone Calls Instead of Face-To-Face Visits a Suitable Alternative for Some Patients, Study Finds......................... 29 Administration for Community Living Announces New Grants for Rehabilitation Research and Training.............................................................. 30

ADVERTISING RATES: Full page = $1500; Half page = $1000; Third page = $750. Ads may be B&W or full color. Contact Ryan Foster, rfoster@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Samantha Schwarz, AMRPA, 529 14th Street, NW, Washington, DC 20045 USA, Phone: +1-202207-1132, Email: sschwarz@amrpa.org Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content ÂŠ2017 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Kellen Company. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th Street, NW, Suite 750, Washington, DC 20045

AMRPA Magazine February 2018

LETTER FROM THE CHAIR

Letter from the Chair Putting the Patient at the Center of Care Richard Kathrins, PhD, CEO, Bacharach Institute for Rehabilitation RKathrins@bacharach.org

few weeks ago I participated in a call with a member of our association who was experiencing a new rash of preadmission denials from a managed Medicare insurance plan. The member explained that all of their recently denied patients had strokes with significant functional deficits and the insurer noted that rehabilitation could be managed with a lower level of care. This story was not a new one but each time we have heard the story, it has created a new wave of disappointment and concern for the patient and their families. At the heart of the denial was patient-centeredness. As healthcare professionals, we strive to meet the principles of patient-centered care. The Institute of Medicine (2001) defines patient centered care as, “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring the patient values guide all clinical decisions” (para 3). From early discharge planning to patient/family conferences and patient team meetings, we try to be responsive to and incorporate patient needs and goals into our treatment plans. In 2016, Marilyn Tavenner of the American Health Insurance Plans (AHIP) and former Center for Medicare and Medicaid Services (CMS) Administrator posted a note stating “….innovators are driving change within the healthcare system to improve the health of our communities we serve. To me, this means putting the patient at the center of the care model” (para 1). It seems that on paper we are all striving to achieve the principles of patient-centered care. A disconnect often exists between an ideal care model and the reality of achieving the principles of the model. Such is the case for the member experiencing pre-admission denials for patients who would best be served at an inpatient rehabilitation facility (IRF). We can also cite examples where the insurer is meeting the principles of patient-centeredness, and in these cases we celebrate their willingness to be transparent and responsive to the needs and wishes of the patient. Most of us have seen and experienced the type of preadmission denial described here and have tried numerous ways to advocate for these patients. We have quoted the recently released Guidelines for Adult Stroke Rehabilitation and Recovery of the American Heart Association/American Stroke Association (Winstein, Stein, Arena,

Bates, Cherney, et al., 2016), and the 2014 study by DaVanzo et al., (2014), titled, Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities and After Discharge. We regularly encourage our patients, acute care partners, and medical staffs (when they have standing), to participate in appeals. These efforts have resulted in mixed outcomes. The campaign to advocate patient by patient can be a challenging one. You are not alone in your efforts. AMRPA is actively advocating on numerous fronts to address concerns about patient access and centeredness. In addition to keeping this issue front and center on our policy agenda, we strive to find ways to work with representatives of managed insurance plans and to press our case with CMS. Our Association also maintains an active Denials Management Committee that is represented by many of our members and Association staff in order to address these and other issues faced by our members. Individually we are accountable to our patients and their families, as are the insurers. Together we need to continue to find common ground to ensure that our patients are able to be involved in their care decisions and understand their rights and the scope of service required to best meet their needs. References DaVanzo, J., El-Gamil, A., Li, J., Shimer, M., Manolov, N., Dobson, A. (2014, July 10). Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities (IRFs) and After Discharge. Retrieved from https://www.amrpa.org/LinkClick.aspx?fileticket=9WtP955B368%3d &tabid=211&portalid=0/ Institute of Medicine (US) Committee on Quality of Health Care in America. Improving the 21st Century Health Care System in Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001. Retrieved from https://www.ncbi. nlm.nih.gov/books/NBK222265/ Tavenner, M. (2016, January 25). Putting Patients First [Blog post]. Retrieved from https://www.ahip.org/putting-patients-first/ Winstein CJ, Stein J, Arena R, Bates B, Cherney L, et al. (2016) Guidelines for adult stroke rehabilitation and recovery. A guideline for healthcare professional from the American Heart Association/American Stroke Association. Stroke, 46, e98-e169.

AMRPA LEGISLATIVE UPDATE

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

Tax Reform Legislation Signed into Law n December 20, 2017, the House and Senate passed the Conference Report to Accompany H.R. 1, The Tax Cuts and Jobs Act. This legislation is considered a significant achievement for a very fractured Republican Party. President Trump signed the bill into law on December 22, 2017, marking a historic revamp of the country’s tax laws for the first time in almost 30 years. H.R. 1 includes several provisions of interest to the IRF sector. Despite significant lobbying by the hospital industry, the final bill does eliminate the •

• • • •

PAYGO is regularly waived. The waiver included in the CR ensures that the cuts will not take effect. Insurance Market Stabilization Legislation May Be Considered Calls for market stabilization legislation intensified following passage of individual mandate repeal in the Republican tax bill, and Sen. Susan Collins (R-ME) is hoping to pass legislation before premiums rise in 2019. Sen. Collins previously indicated she would not support the tax bill unless Senate Majority Leader Mitch McConnell

Before leaving for the year-end holidays Congress passed a Continuing Resolution (CR) that funded the government through January 19, 2018. This package unfortunately did not include several Medicare extender policies that expired at the end of December 2017, including a repeal of the therapy caps. Congress likely needs additional time to negotiate a long-term FY 2018 “Omnibus” Budget package, so another CR through mid-February is expected. Senate Finance Committee Chairman Orrin Hatch (R-UT) announced that he plans to retire at the end of his term and will not seek re-election in 2018. HHS Secretary Designate, Alex Azar, is expected to be confirmed by the full Senate. CMS announced its first new bundled payment mode, the Bundled Payments for Care Improvement Advanced (BPCI Advanced).

ability of hospitals to access tax-exempt “advance refundings” of outstanding taxexempt bonds beginning in 2018. The health care sector advocated intensely for the maintenance of the medical expense deduction. Individuals can deduct medical expenses that are greater than 7.5 percent of adjusted gross income (AGI), but the deduction will increase to 10 percent of

AGI after two years. With the doubling of the standard deduction, fewer Americans are expected to use it. The orphan drug tax credit decreases from 50 percent to 25 percent, which is the tax credit pharmaceutical companies receive for qualified clinical trial costs. Republicans successfully repealed the Affordable Care Act’s (ACA) individual mandate in 2019. The law removes the penalty fee of $695 per adult or 2.5 percent of household income (whichever is higher, maximum of $2,085). The mandate would still apply for 2018.

Final action by the President was temporarily delayed until lawmakers passed a Continuing Resolution (CR) that included a waiver of statutory “pay-asyou-go” or PAYGO rules, which requires automatic, across-the-board cuts to certain mandatory spending programs, including Medicare, if legislation is enacted that increases the deficit, although statutory

(R-KY) held votes on the Alexander-Murray plan, which would fund cost-sharing reduction (CSR) payments, and her own reinsurance bill. She later backed off that demand, explaining that it was most important to pass stabilization legislation before the mandate repeal takes effect in 2019. It remains unclear whether a market stabilization bill could garner the support AMRPA Magazine February 2018

of House Republicans, who have so far resisted the idea. FY 2018 Funding Continues with Series of Continuing Resolutions Shortly before funding for the federal government expired, the House and Senate on December 21, 2017, voted to pass a Continuing Resolution (CR) through January 19, 2018. The CR authorizes $550 million for Community Health Centers and includes $2.85 billion for the Children’s Health Insurance Program (CHIP) for the first two quarters of FY 2018 (October 1, 2017, through March 31, 2018) along with extended flexibility for the Centers for Medicare and Medicaid (CMS) to use unused CHIP funds. The CR also provides $2.1 billion for funding for the Veterans Choice program. The House quickly recessed and left town, and the Senate voted 66-32 to pass the CR.

Next Grouping of Medicare Extenders Expire, Temporary CHIP Funding Running Out Due to the limited time available before federal government funding expired, Congress did not include Medicare extender policies, such as the bipartisan, bicameral and tri-committee permanent therapy caps repeal policy proposal, in the December 21 CR. Several Medicare extenders, including the therapy caps, expired at the end of 2017. While it is possible these could be included in the next short-term spending bill, Republican Leadership is leaning toward adding the provisions to an Omnibus spending package in order to drive support for the deal. The Medicare extenders community is pushing for at least a patch extension retroactive to the start of the year and until a more comprehensive funding package is hopefully passed in February.

Negotiations are underway on a highlevel budget agreement that would set spending levels for Fiscal Year (FY) 2018 ahead of an “Omnibus” Appropriations package, which is more likely to move in mid-February. Congress was expected to pass another stopgap spending bill before January 19, giving Congressional Appropriators additional time to draft the Omnibus.

The permanent policy will repeal the therapy caps, but require an appropriate modifier to be included on claims submitted over the new $3,000 threshold, in order to ensure that therapy services are medically necessary, and continue targeted medical review of claims established by the Medicare Access and CHIP Reauthorization Act (MACRA). AMRPA led an effort with the Therapy

Caps Coalition to develop additional legislative language that requires a study on the impact of the new policy changes on Medicare beneficiary access. The study specifically calls for a review of all claims above the $3,000 annual threshold, as the highest utilizers of outpatient therapy services are often medically complex, suffering from multiple chronic conditions. While no legislative text has been released at this point, AMRPA and other received assurances that the study was positively received by Committee staff, and we continue to advocate for its inclusion. We would appreciate your help by reaching out to your members of Congress to urge their support for repeal of the therapy caps and inclusion of a study to assess the impact of the new policy. As noted above, the CR that passed in late December funds the Children’s Health Insurance Program (CHIP) only through March 31, 2018. Lawmakers still plan to pass a full reauthorization of the program early this year. Meanwhile, the Congressional Budget Office (CBO) has slashed its cost estimate for a five-year reauthorization from $7.5 billion to $800 million. The CBO’s updated score reflects the repeal of the individual mandate included in the Republican tax reform bill. The lower cost estimate should ease negotiations over 5

CHIP as lawmakers negotiate and finalize FY 2018 omnibus deal. Some States, however, indicate they may run out of funding as early as January 19. 2018 Health Care Outlook Looking ahead, several important health care issues remain on the agenda for possible action in 2018. Notably, Congress must complete work on the pending FY 2018 appropriations bills, which are expected to move as part of a broader Budget deal. As previously noted, repeal or delay of ACA taxes also may be addressed in that context.

repealing the ACA’s individual mandate. President Trump continues to rebuke the pharmaceutical industry over high drug prices, but it is unclear whether this presages forthcoming executive action. Some reports suggest the president could soon sign a final Executive Order on drug pricing. Lawmakers in Congress have expressed growing frustration over prescription drug costs, and legislative proposals to address the issue could be advanced in 2018. There is wide agreement that additional funding will be needed for the federal government to respond effectively to the opioid epidemic. The Administration did not announce any new funding when it declared a public health emergency, however, and HHS Acting Secretary Hargan has indicated that the White

Finance Committee on January 9 during a hearing that was largely without fireworks. As expected, questions mostly zeroed in on his thoughts around high prescription drug prices. Mr. Azar defended his time as president of Lilly USA, arguing that the company’s price hikes were in line with general industry trends and the result of system-wide incentives for higher list prices. He added that he believes strong generic competition can help address the problem. He also noted that he would support mandatory payment models if necessary “to get adequate data.” Mr. Azar, a former Deputy Secretary at HHS, is expected to be confirmed by the full Senate.

Congress included in its year-end spending bill a short-term extension of CHIP funding through March 31, giving lawmakers time to negotiate a full reauthorization when they return in January. Notably, the yearend package did not include any Medicare extenders. Congress will likely address these early in the year; based on prior precedent, extension of these payments are likely to have a retroactive We effect.

CMS Announces New Bundled Payment Model On January 9, the Centers for Medicare and Medicaid Services (CMS) announced the launch of a new bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced). The model will qualify as an Advanced Alternative Payment Model, under the Quality urge AMRPA members to Payment Program within MACRA. come to Washington, DC, to Building off of previous Innovation participate in AMRPA’s upcoming Center models and stakeholder President Trump also has input, the model is an expansion urged Congress to return to March 12-13 Spring Conference of past BPCI models, and will add broader ACA repeal efforts and Congressional Fly-In. outpatient episodes, such as back early in the year and to use the and neck except spinal fusion. FY 2019 Budget Resolution to The 29 inpatient clinical episodes pass a revived Graham-Cassidy include back and neck except spinal fusion, bill through the Budget Reconciliation House will defer to Congress on additional double joint replacement of the lower process. For Senate Republicans, however, appropriations. With concern mounting extremity, fractures of the femur and hip or the path to 50 votes remains uncertain. over the crisis, additional funding to fight pelvis, among others. Applications are due Further, Republicans’ decision to include opioid abuse may be included in a larger by March 12, 2018. a repeal of the individual mandate in their spending package. tax reform bill actually may complicate the ACA repeal effort. Indeed, Senators *** The White House reportedly plans to Graham and Cassidy have said their Since Congress was unable to resolve several release its FY 2019 Budget in February. legislation would need to be revamped in outstanding health care issues, such as CHIP Consistent with the President’s FY 2018 order to adjust for the loss of savings from reauthorization and Medicare extenders, we Budget, many expect the Administration repealing the mandate. expect a very busy start to 2018. We urge will propose significant cuts to federal AMRPA members to come to Washington, agencies in addition to the hiring DC, to participate in AMRPA’s upcoming Eliminating the mandate also is likely to restrictions that remain in place for most of March 12-13 Spring Conference and strain insurance markets further, putting HHS. The Budget also may reflect recent Congressional Fly-In. Entitlement reform increased pressure on Congress to act proposals by House Speaker Paul Ryan (Rappears to be part of the 2018 Republican before the midterm elections. This may WI) to advance broader reforms to federal agenda so it will be a critical time to get include the passage of market stabilization entitlement programs, including Medicare in front of policymakers to discuss several legislation, such as a proposal from and Medicaid. important policy issues, such as value-based Senators Lamar Alexander (R-TN) and Patty purchasing, implementation of the IMPACT Murray (D-WA) to fund CSR payments, Senate Finance Committee Holds HHS Act, and issues related to managed care. as well as potential funding for state Secretary Confirmation Hearing Please do not hesitate to reach out if you reinsurance programs. The Congressional have any questions about the Fly-in and/or Budget Office (CBO) has advised, however, Alex Azar, the President’s nominee to AMRPA’s legislative priorities. that passage of the Alexander-Murray serve as Secretary of Health and Human plan alone would not offset the impact of Services, testified before the Senate 6

AMRPA Magazine February 2018

March 11-13, 2018 Embassy Row Hotel • Washington, DC Registration is Open Visit us at www.amrpa.org for the agenda, CE credit information, and to register today. Congressional Fly-In – earn credit while hearing updates directly from federal agency officials and policy influencers in the morning, and then join us prepared for Hill visits scheduled by AMRPA in the afternoon. (March 12-13) Medical Directors Symposium - provide your physician leadership with the knowledge and networking opportunities they need to stay informed on the latest issues in the field. (March 11) Rehabilitation Administrators Workshop – an opportunity for your operational leadership to cover or revisit the basics of regulations for inpatient medical rehabilitation hospitals and units. (March 11) Know someone who is a nonmember? Nonmembers who register for the conference receive a 6 month free trial membership for their organization! Questions? Contact Samantha Schwarz, AMRPA Member Services Coordinator, at sschwarz@amrpa.org or by calling 202-207-1132.

#AMRPA 7

CMS AND OMHA TRY TO LIMIT THE ALJ BACKLOG

s it struggles to deal with the overwhelming backlog of appeals, the Centers for Medicare and Medicaid Services (CMS) continue to develop new initiatives and tools to assist while simultaneously turning a blind eye to or pleading incapacity for some of the most promising alternatives. This has the interesting effect of making the Office of Medicare Hearings and Appeals (OMHA) appear busy but ineffective. For instance, OMHA continues to expend resources on an electronic case management system that was supposed to roll out last year but is still not genuinely useful. Meanwhile, administrative law judges (ALJs) are waiting for additional staffing to help them wade through their extensive caseloads as Congress moves toward its fourth Continuing Resolution (CR) in as many months. OMHAâ&#x20AC;&#x2122;s primary focus continues to be on its various settlement and case-expediting initiatives such as the Settlement Conference Facilitation (SCF) initiative and its hearing options for sampling and extrapolation. But OMHA is beholden to CMS as a facilitator for its most effective options, which primarily involve global settlement of certain types of cases. The newest tool being implemented is the Low-Volume Appeals (LVA) Settlement Option. In the meantime, the Department of Health and Human Services (HHS) continues to fight against the imposition of any real measures designed to actually eliminate the backlog such as widespread settlements in the AHA v. Hargan (previously AHA v. Price) federal court case. There is a glimmer of hope for a potential global settlement offer for inpatient rehabilitation hospitals and units (IRH/ Us), as disclosed in the November 2017 deposition of George Mills, deputy director of the Center for Program Integrity at CMS. The remainder of this article lays sheds light on ongoing discussions with CMS about a potential 8

settlement option for IRH/Us as well as additional information on the LVA Settlement Option, which admittedly, is not particularly applicable to IRF/Us. Global IRF Settlement Under Discussion While most IRH/Us will not be able to take advantage of the LVA settlement option discussed more fully below, AMRPA has been working with other stakeholders in the IRH/U provider community, such as the Fund for Access to Inpatient Rehabilitation (FAIR Fund), to negotiate an industry-wide global settlement option for IRH/Us with CMS. Until recently, this information has remained confidential in order to facilitate open discussions with CMS officials. However, the negotiations became public as part of a November 2017 deposition given by George Mills of CMS in the AHA v. Hargan case. In light of this disclosure, AMRPA wishes to share background information on the negotiations with its members. Currently between 15,000 and 20,000 IRH/U claims are tied up in the appeals backlog. A global settlement would allow the individual appellants to choose whether to accept a negotiated percentage of the Medicare allowed amounts for its appeals within that backlog. Talks were initiated with CMS in May 2015. Prior to entering into talks with CMS, AMRPA surveyed its members regarding their pending appeals and the outcomes of previously resolved appeals. Based on the responses of 249 IRH/Us, the IRH/U stakeholders approached CMS with a proposed settlement percentage based on the dollar amount of favorable appeals won by the responding IRH/Us. A second proposal was put forward in July 2015 based on the overall percentage of favorable appeals. Unfortunately, following the July 2015 proposal, CMS withdrew from the negotiations, without making a counteroffer.

ABOUT THE AUTHORS

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

Christina A Hughes, J.D., MPH, Counsel, Powers Law Firm

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

Following overtures from CMS, IRH/U stakeholders resumed discussion with CMS officials in mid-2017. Those negotiations AMRPA Magazine February 2018

are ongoing and have been raised as part of the AHA suit, partially as evidence of CMS’ failure to pursue all realistic possibilities for reducing the OMHA appeal backlog. In its most recent filing with the court, HHS raised concerns about entering into widespread settlements due to the lack of homogeneity between the appeals included and also due to program integrity concerns raised by some of the appellants in the backlog. Nonetheless, with respect to a possible global settlement with IRH/Us, AMRPA believes there are strong factors in favor of reaching an ultimate settlement offer with CMS. First and foremost, with the AHA suit ongoing, there is strong pressure on CMS to pursue all reasonable methods of resolving the backlog—obviously a settlement involving 15,000-20,000 claims would not solve the problem entirely but it would show a good faith effort of addressing the backlog. In addition, CMS has shown itself to be open to industryspecific settlements, first with the two acute care patient status settlements and now with the LVA settlement option. (CMS acknowledges that most of the appellants able to take advantage of the LVA settlement are durable medical equipment (DME) suppliers, which

represent an industry CMS asserts has a disproportionate number of program integrity concerns.)

lack of prior level of function or therapy intensity on the PAS may no longer stand up under an ALJ’s scrutiny.

Two additional factors also support CMS being favorable to a global settlement approach for IRH/Us. While there are not as many claims in the IRH/U category, the value of the claims is higher than many others in the backlog. Thus, when those appeals are finally resolved, many of the providers could be due substantial amounts of interest on their claims (assuming the claims were denied through post-payment review, as opposed to prepayment review). While CMS is motivated to avoid paying meritless claims, they are also cognizant of the drain on Medicare funds that such appeals represent.

As noted, negotiations are ongoing and final agreement on a global settlement for IRH/Us is not yet in sight. AMRPA will continue to work with CMS and other IRH/U stakeholders to achieve meaningful progress for its members in navigating the deadlocked ALJ appeal process.

Finally, a 2017 court case (Cumberland County Hospital System Inc. v. Price) involves a ruling that has the potential to significantly undermine the arguments available to CMS and its contractors in the case of technical denials. The court ruled that any requirements for the preadmission screening (PAS) document that are not specifically listed in the applicable regulation are essentially non-binding guidance. Therefore, many technical denials on issues such as the

Low-Volume Appeals Settlement Option As mentioned in the December 2017 issue, CMS recently announced an initiative to settle all eligible appeals for so-called “low-volume” appellants. The settlement option is now underway and deadlines for participation will soon expire (March 9, 2018) for certain providers. While it is unlikely that many IRH/Us will be able to take advantage of the LVA settlement option due to the low cap on individual claim values, it is critical that those interested take careful note of the deadlines and other requirements for the initiative as described below. February 5, 2018, is the first day that CMS will accept applications for LVA settlements from Medicare providers with appeals 9

pending at OMHA and the Medicare Appeals Council (Council). Under the LVA settlement option, providers can agree to accept 62 percent of the net Medicare approved amount of all of their currently denied claims with appeals pending at OMHA or the Council that are for billed amounts of $9,000 or less. Under the LVA, like all other settlement options offered by CMS, the provider must settle all of their eligible claims that meet the criteria under this settlement at 62 percent, and cannot pick and choose which claims to settle.

notify the provider within 30 days of submission, including instructions on how to dispute the eligibility decision, which must be done within 15 days of receiving a determination. If CMS determines a provider is eligible, the provider will receive an agreement along with a spreadsheet of potentially eligible appeals within 30 days of submission of the EOI. After reviewing the spreadsheet, if the provider concurs with the appeals that CMS has included in the spreadsheet and wants to proceed, the provider should sign the agreement and send it to CMS within 15 days of receipt of the agreement and spreadsheet. If the provider believes

In addition to being less than $9,000, an appeal must have been pending before the OMHA and/or Council level of appeal as of November 3, 2017, in order to be eligible for this settlement. The claim must also currently be in fully denied status in the Medicare system and the For providers with NPIs ending claim cannot be part of an an even number, EOIs will be extrapolation-based denial.

(MAC) for final eligibility verification and payment amount. CMS states that there is a possibility that during the final validation, appeals and associated claims may be removed from the settlement for not meeting eligibility criteria and that a provider will be notified if that occurs. Any unsettled claims will be returned to their original place in the appeals queue. Payment on the settled claims will be made within 180 days of CMSâ&#x20AC;&#x2122; signature on the agreement. CMS states that the final net settlement amount for a provider will not be available before the agreement is signed and will be determined after the settlement agreement has been signed by both parties. CMS further advises that the MACs will price each claim individually, and that any issues that arise on the final amount paid should be resolved between the provider and the MAC.

CMS has a webpage dedicated to this settlement accepted from February 5, 2018, with more detailed Medicare Part A and Part B through March 9, 2018. For providers instructions, forms, and a list providers, physicians, and with NPIs ending in an odd number, of frequently asked questions. suppliers are eligible for this The web address is: https:// settlement if they have less EOIs will be accepted on March 12, than 500 appeals pending w w w. c m s . g o v / M e d i c a r e / 2018, through April 11, 2018. at OMHA and the Council, Appeals-and-Grievances/ when combining all of their OrgMedFFSAppeals/Appealsassociated National Provider Settlement-Initiatives/LowIdentifiers (NPIs). Beneficiaries, Volume-Appeals-Initiative. the spreadsheet contains appeals that state Medicaid organizations and certain html. CMS also has a dedicated email inbox should not be included or the spreadsheet providers that have program integrity for questions: MedicareSettlementFAQs@ is missing appeals, the provider can concerns or litigation pending, including cms.hhs.gov. submit an eligibility determination pending civil, criminal, or administrative request (EDR) within 15 calendar days of investigations, are not eligible. Conclusion receiving its agreement and spreadsheet. Many IRH/Us with appeals pending in This EDR form and specific instructions There will be several steps involved for before OMHA are starting to see some are available by following the link at the a provider who decides to participate in slow progress, with appeals filed in 2013 end of this article. CMS will take 30 days the LVA. First, the provider must submit beginning to be scheduled for hearings. to review any EDRs submitted before an expression of interest (EOI) form for Checking the case status database providing a final list of eligible appeals for each of its NPIs. The EOI form is available (AASIS) may provide some insight as the settlement. on the CMS webpage by following the to whether any progress has occurred link provided at the end of this article. for individual appellants. Other options Within 15 days of receiving the final For providers with NPIs ending in an such as the SCF initiative and sampling spreadsheet and agreement, the provider even number, EOIs will be accepted from options also remain viable. Otherwise, must submit the signed agreement. Once February 5, 2018, through March 9, 2018. AMRPA will provide updates on other a signed agreement has been received For providers with NPIs ending in an odd available avenues and any progress on on time by CMS, CMS will countersign number, EOIs will be accepted on March achieving global settlement for IRH/Us in the agreement and send a copy to 12, 2018, through April 11, 2018. the coming months. the provider. At this point the appeals included in the spreadsheet are removed After submitting an EOI, CMS will review from the appeals process. The settlement to determine provider eligibility for the is then sent to the providerâ&#x20AC;&#x2122;s associated settlement. If CMS determines a provider Medicare Administrative Contractor does not meet eligibility criteria, it will 10

AMRPA Magazine February 2018

WHAT IS A PPS COORDINATOR SUPPOSED TO DO? By Lisa Werner, MBA, MS, CCC-SLP

larifying the specific role of a PPS (Prospective Payment System) coordinator is one of the most frequent requests I receive. Because the tasks required of PPS coordinators differ based on the unique characteristics of each rehab facility, it’s difficult to come up with a general answer for all coordinator roles across the nation. Since beginning my on-site consultations in 2002, I have yet to come across two distinct facilities that expect their coordinators to perform the same functions.

original rehabilitation goals. They should also include information necessary to determine the CMG and tier of the impairment group codes (IGC), ages, functional independence measure (FIM) scores, and comorbidities. Of course, patient identification, admission, payer, medical information, and quality indicators are all part of the initial assessment as well.

entering this information, but someone with clinical knowledge should always check the IRF-PAI for any of the errors discussed above before it is considered complete.

2. Managing Stays I’ve witnessed a variety of ways in which hospitals and units involve PPS coordinators in managing patient stays. In some instances, coordinators will attend team conferences in order to listen to discussions, where they gather information for coding purposes, obtain This may be somewhat of a information for utilization The most important idea … is the Sisyphean task, but my intent reviews, learn the justifications importance of accurate IRF-PAI is to help define the key for continuing stays, and duties for PPS coordinators completion and how it can affect validate the burdens of that should remain relevant care. However, I have also your facility’s reimbursement. regardless of the hospital or seen many cases where unit. From this list, I hope you When allocating resources for PPS the discussions in team are able to develop checklist conferences are not robust management, make sure to supply of sorts in order to consistently enough for the coordinators coordinators with ample time to identify who is responsible for to garner all the information what task, what checks are review all team documentation from they need, rendering their in place to make sure those presence unnecessary. Pay the first three days of patients’ stays tasks are completed, and how close attention to team to most effectively manage in order to verify the true burdens of conference discussions and these roles. make sure that they focus on care in terms of FIM scores, quality maximizing every opportunity indicators, and ICD-10 codes. available to evaluate the 1. Starting an IRF-PAI accuracy of the information While the admission IRFreported on the IRF-PAI. PAI should be coded by the end of the fourth rehab day in all Does your PPS coordinator currently PPS coordinators can also take on circumstances, rehabilitation units and complete this task? If they enter FIM the role of managing the eRD tab hospitals should make every attempt to scores, quality indicator codes, and in the eRehabData® IRF-PAI, which complete the admission IRF-PAI as soon medical codes, they should have ample calculates 60 percent rule compliance. as all the necessary data is available. If clinical knowledge and be able to The documentation must be reviewed it is not completed by the seventh day, understand eRehabData® warnings as to determine the primary justifications it is considered late. IRF-PAI’s with case well as respond to them. They should for admission. If the justifications for mix groups will help you appropriately also be able to spot unlikely or unusual admission do not translate into compliant manage patient stays by giving you the conditions and levels of function which IGC’s or diagnoses, but a presumptively ability to monitor all actively treated highlight potential data entry or coding compliant ICD-9 code is reported on the medical conditions and comply with your errors. It is tempting to use a data clerk for 11

IRF-PAI, the coordinator then must review the records to verify that the patient would have been admitted regardless of the reported admitting condition. It is the coordinator’s responsibility to make sure that their facility’s 60 percent rule compliance report accurately reflects the information in patients’ records. 3. Closing the Case When patients are discharged, PPS coordinators receive final codes, final FIM scores, and enter them into the IRFPAI along with the discharge codes. The coordinator’s most important role during this phase is to review documentation from the final days of each patient’s stay in order to identify the 24-hour period that represents the patients’ highest overall levels of function. This allows for the lowest scores from that day to be accurately reported. Coordinators should also review coding attestation and select codes from the IRF-PAI that represent all actively treated conditions requiring clinical assessment, interventions, or consumable resources. This includes conditions that may have complicated the stay, had the potential 12

to complicate the stay if not properly managed, or added to the overall burden of care. Finally, the discharge destination and all other pertinent information must be completed before closing the document. Once the IRF-PAI has been thoroughly finished, it is the PPS coordinator’s responsibility to lock and transmit the assessment to CMS. While we most likely agree that many of the duties stated above are essential to the role of the PPS coordinator, these tasks are only a small sample of the duties they may be expected to undertake. I have seen everything from FIM training and QI coordination to utilization review coordination, case management, and chart auditing assigned to PPS coordinators. While these tasks do pair nicely with the skillsets and expertise of PPS coordinators, they also add tremendously to their overall workload. This makes it nearly impossible to recommend a general, ideal number of beds to assign to each coordinator. In case manager driven models, where the case manager takes

on the responsibilities of completing the IRF-PAI, PPS coordinator caseloads average around 12 to 14 patients. In situations where PPS coordinators are only responsible for IRF-PAI completion without any of the additional tasks listed, I’ve seen caseloads of up to 60 patients per coordinator. The most important idea to take away from this article is the importance of accurate IRF-PAI completion and how it can affect your facility’s reimbursement. When allocating resources for PPS management, make sure to supply coordinators with ample time to review all team documentation from the first three days of patients’ stays in order to verify the true burdens of care in terms of FIM scores, quality indicators, and ICD-10 codes. The same is true upon discharge, where coordinators must be given time to review and verify the accuracy of discharge scores and codes. Cutting corners in this position could come back to haunt both you and your facilities once reimbursements are released.

AMRPA Magazine February 2018

TRICARE PUBLISHES FINAL RULE ON PAYMENT FOR IRFS AND LONG-TERM CARE HOSPITALS By Carolyn C. Zollar, MA, JD, Executive Vice President of Government Relations and Policy Development, AMRPA

n December 29, 2017, the Medicare program published its final rule on payment for inpatient rehabilitation facilities (IRFs) and long-term care hospitals (LTCHs) utilizing Medicare payment rates. The effective date for this rule is March 5, 2018. TRICARE had issued a proposed rule in August 2016 and AMRPA filed an extensive comment letter. This final rule adopts many of the proposals in the initial rule but, fortunately, instead of proposing practically immediate implementation it allows for a three-year phase-in. However, the allowed amounts for payment from TRICARE will be reduced by 36 percent, as opposed to 40 percent in the proposed rule. Currently, TRICARE pays IRFs the lower of a negotiated rate or billed charges. Phase-in of Medicare Payment for TRICARE In its comment letter, AMRPA had vociferously argued for a transition period for implementation. TRICARE explicitly recognized the multiple provider recommendations for a transition. Payment will be phased in over three years as follows: •

Allowing 135 percent of Medicare IRF PPS amounts in the first 12-month period after implementation;

•

115 percent in the second 12-month period after implementation; and

•

100 percent in the third 12-month period after implementation, and follow Medicare’s policies during subsequent fiscal years.

The Department of Defense (DoD) will apply the FY 2019 IRF PPS for purpose of the 12-month period beginning on October 1, 2018, and follow any changes made by Medicare to the IRF PPS for subsequent years. Special Payment Policies TRICARE is also adopting Medicare’s IRF adjustments for interrupted stays, short stays of less than three days, short stay transfers, high cost outliers and the lowincome patient (LIP) adjustment. Sixty Percent Rule There was some confusion in the original proposal regarding the 60 percent rule. TRICARE states in this rule that, “It was the intent of the policy to note that TRICARE would honor the Medicare adjustments based on fulfilling the criteria of the 60 percent rule with Medicare patients and not that TRICARE would require a 60 percent rule for its own patients. In other words, if Medicare penalizes an IRF because the IRF did not meet the 60 percent rule criteria with Medicare patients, TRICARE would also penalize the hospital. This is because TRICARE would use the same grouping software as Medicare, which already includes the 60 percent rule adjustments.” General Temporary Military Contingency Payment Adjustment (GTMCPA) In response to public comments, the rule includes authority for a year-end, discretionary GTMCPA that the Director or Defense Health Agency (DHA) may approve in extraordinary economic circumstances for inpatient services from TRICARE network IRFs deemed to be

essential for military readiness and support during contingency operations. The Director, DHA, or designee, may approve a GTMCPA for network IRFs that serve a disproportionate share of active duty service members (ADSMs) and active duty dependents (ADDs). Specific procedures for requesting an IRF GTMCPA are yet to come and will be outlined in the TRICARE Reimbursement Manual. Changed Terminology The rule adopts Medicare’s definitions to LTCHs and IRFs, which state: “(xx) Inpatient Rehabilitation Facility (IRF). IRFs must meet all the criteria for classification as an IRF under 42 CFR part 412, subpart B, and meet all applicable requirements established in this part in order to be considered an authorized IRF under the TRICARE program. (A) In order for the services of inpatient rehabilitation facilities to be covered, the facility must comply with the provisions outlined in paragraph (b)(4) (i) of this section. In addition, in order for services provided by these facilities to be covered by TRICARE, they must be primarily for the treatment of the presenting illness. (B) Custodial or domiciliary care is not coverable under TRICARE, even if rendered in an otherwise authorized inpatient rehabilitation facility. (C) The controlling factor in determining whether a beneficiary’s stay in an inpatient rehabilitation facility is coverable by TRICARE is the level of professional care, supervision, and skilled nursing care that the 13

beneficiary requires, in addition to the diagnosis, type of condition, or degree of functional limitations. The type and level of medical services required or rendered is controlling for purposes of extending TRICARE benefits; not the type of provider or condition of the beneficiary.” The final rule, TRICARE; Reimbursement of Long-term Care Hospitals and Inpatient Rehabilitation Facilities, was published in the Federal Register on December 29, 2017.

Table 1: Reductions in TRICARE Allowed Amounts Under Proposed Policy During Transition Period Transition Schedule Percent of Medicare Allowed Payments

Reductions Under Proposed Policy (Millions) LTCH

IRF

FY 19

135%

$73

$24

FY 20

115%

$86

$41

FY 21

100%

$98

$57

THINK ABOUT IT…

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

AMRPA Magazine February 2018

MEDPAC ISSUES POST-ACUTE CARE PAYMENT RECOMMENDATIONS FOR FY 2019 By Mimi Zhang, Policy and Research Associate, AMRPA

n January 11, the Medicare Payment Advisory Commission (MedPAC) met to vote on its fiscal year (FY) 2019 payment recommendations for inclusion in its March 2018 Report to Congress on Medicare payment policy. As anticipated, the Commission approved the Chairman’s draft recommendation to reduce inpatient rehabilitation facility (IRF) payments by 5 percent for FY 2019. The Commission also intends to reiterate its March 2016 recommendations for the Secretary of Health and Human Services to assess the integrity of the IRF PPS through focused medical reviews and to expand the outlier pool to redistribute payments the sector. Additionally, the Commission approved a separate recommendation to redistribute payments within each post-acute care (PAC) setting using a blended-rate method derived from MedPAC’s unified PAC prospective payment system (PAC PPS). In advance of the meeting, AMRPA submitted a letter to MedPAC providing our comments on the recommendations and specifically to urge their rejection. The letter is reproduced in this issue of the magazine. Increasing Payment Equity: PAC PPS Payment Redistribution MedPAC staff started with a brief presentation on “an approach to increase the equity of payments within each setting.” A fully implemented unified PAC PPS would redistribute payments across conditions. Prior to implementing the unified PPS, MedPAC staff recommend using a blend of setting-specific and unified PAC PPS relative weights to establish payments. This would help transition PAC providers to the different payment incentives of the unified PAC PPS.

Within each setting, payments would be redistributed across conditions and, based on patient mix and therapy practices, across providers. According to MedPAC, blending the PAC PPS and setting-specific relative weights would increase the equity of payments, begin to correct “known biases” of current PPSs, and give providers more time to make changes. The Commissioners finalized the following recommendation: Recommendation: The Congress should direct the Secretary to begin to base Medicare payments to postacute care (PAC) providers on a blend of each sector’s setting-specific relative weights and the unified PAC prospective payment system’s relative weights in fiscal year 2019. Implications: •

Spending: Relative to current law, no change

•

Beneficiary and provider: Access will be more equitable, increasing for medically complex beneficiaries. Providers will have less incentive to selectively admit beneficiaries based on their condition. Disparities in Medicare margins across providers will be reduced. The impact on individual providers will vary based on their mix of cases and current practice patterns.

Inpatient Rehabilitation Facilities MedPAC staff then moved into presentations on assessing Medicare fee-for-service payment adequacy and updating payments for PAC providers. For IRFs, supply and volume remained steady in 2016, and quality has been improving since 2011. The aggregate Medicare margin for 2016 was

13.0 percent, and the projected aggregate Medicare margin for 2018 is 11.9 percent. Staff stated that payments to IRFs remain “well above” the costs of caring for beneficiaries. The Commissioners finalized the following recommendation: Recommendation: The Congress should reduce the fiscal year 2019 Medicare payment rate for inpatient rehabilitation facilities by 5 percent. Implications: •

Spending: Decrease relative to statutory update by between $250 million and $750 million in 2018; by between $1 billion and $5 billion over five years.

•

Beneficiary and provider: No adverse effect on Medicare beneficiaries’ access to care or out-of-pocket spending. May increase financial pressure on some providers, but effect should be eased by an accompanying expansion in the outlier pool (as recommended last year).

Skilled Nursing Facilities MedPAC staff stated that skilled nursing facilities’ (SNFs) supply is steady and access to capital is adequate in 2016, though continue to show mixed results for quality of care. In 2016, the Medicare margin for SNFs was 11.4 percent. The projected Medicare margin for 2018 is 9 percent. Staff stated that margins remain too high and that the SNF PPS needs to be revised. The Commissioners finalized following recommendation:

Recommendation: The Congress should: •

Eliminate the market basket update for skilled nursing facilities for fiscal years 2019 and 2020.

•

Direct the Secretary to implement a redesigned prospective payment system (PPS) in fiscal year 2019 for skilled nursing facilities; and

•

Direct the Secretary to report to the Congress on the impacts of the revised PPS and make any additional adjustments to payments needed to more closely align payments with costs in fiscal year 2021.

Implications: •

•

Spending: Decrease relative to current law by between $750 million and $2 billion in FY 2019; by more than $10 billion over five years Beneficiary and provider: MedPAC does not expect adverse impacts on beneficiaries. Access will increase for medically complex beneficiaries. Providers will continue to treat beneficiaries. The impact on individual providers will vary based on their mix of cases and current practice patterns. Disparities in Medicare margins across providers will be reduced.

Home Health Care MedPAC staff gave an overview of home health care services, stating that indicators are positive and similar to results from prior 16

years. Access is adequate and supply remains high. With regard to quality, functional measures show improvement while the rates of adverse events were unchanged in 2016. The Medicare margin for 2016 was 15.5 percent, and the projected Medicare margin for 2018 is 14.4 percent. Staff said key objectives to revise the PPS include more closely aligning payments with costs and rebalancing payments so that agencies do not favor therapy services over non-therapy services. The Commissioners finalized following recommendation: Recommendation: The Congress should reduce Medicare payments to home health agencies by 5 percent in CY 2019, and implement a two-year rebasing of the payment system beginning in 2020. The Congress should direct the Secretary to revise the prospective payment system to eliminate the use of therapy visits as a factor in payment determinations, concurrent with rebasing.

Elimination of therapy thresholds would redistribute payments among providers. Long-term Care Hospitals LTCH occupancy remains stable, even as volume continues to decline. Quality is stable or improving for the limited available aggregate measures. The 2016 Medicare margin for all cases was 4.1 percent, while the 2016 margin for qualifying cases was 6.3 percent. The projected margin for qualifying cases in 2018 is 4.7 percent. Commissioners proceeded to a vote on the following draft recommendation: Recommendation: The Congress should eliminate the fiscal year 2019 Medicare payment update for longterm care hospitals. Implications: •

Spending: Decrease relative to the statutory payment update by between $50 million and $250 million in 2019; less than $1 billion over five years

•

Beneficiary and provider: No adverse impact on beneficiaries expected. Absence of update is not expected to affect providers’ willingness and ability to care for Medicare beneficiaries.

Implications: •

Spending: Decrease relative to current law by $750 million to $2 billion in 2019 and $5 billion to $10 billion over five years.

•

Beneficiary and provider: Access will increase for medically complex beneficiaries. Payments would be lower for all providers relative to current law. Lower payments should not affect providers’ willingness to deliver appropriate home health care.

*** These recommendations will be reflected in MedPAC’s March 2018 Report to Congress. MedPAC meets next on March 1-2, 2018.

AMRPA Magazine February 2018

CMS ANNOUNCES NEW VOLUNTARY BUNDLED PAYMENT MODEL: BPCI ADVANCED By Mimi Zhang, Policy and Research Associate, and Lovelyn Robinson, Editorial and Research Assistant

n January 9, the Centers for Medicare and Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) launched a new voluntary bundled payment model, the Bundled Payments for Care Improvement Advanced (BPCI Advanced). The model, which is in step with the Trump administration’s preference for voluntary initiatives, will test bundled payments for 32 clinical episodes and aims to assist participating health care providers in reducing costs and improving quality of care. BPCI Advanced will also qualify as an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program (QPP). In a change from the original BPCI models announced in 2011, BPCI Advanced will not include any episodes that initiate with the post-acute care service (unlike Model 3 of the original BPCI). Only acute care hospitals and physician group practices (PGPs) can be episode initiators in BPCI Advanced. Other providers and suppliers can participate as non-episode initiating conveners that facilitate coordination

among episode financial risk.

initiators

and

bear

BPCI Advanced Model BPCI Advanced will operate under a totalcost-of-care concept in which the total Medicare fee for service (FFS) spending on all items and services furnished to a BPCI Advanced beneficiary during the Clinical Episode are taken into account to determine the Target Price and reconciliation calculations. Payments to Participants will be also linked to quality using a pay-for-performance methodology based on participants’ performance on specific quality measures. The BPCI Advanced Clinical Episode will begin either at the start of an inpatient admission to an acute care hospital (the Anchor Stay) or at the start of an outpatient procedure (the Anchor Procedure). Inpatient admissions that qualify as an Anchor Stay will be identified by MS-DRGs, and outpatient procedures that qualify as an Anchor Procedure will be identified by HCPCS codes. The Clinical Episode will end 90 days after the end of the Anchor Stay or the Anchor Procedure.

Highlights: •

•

Acute care hospitals and physician group practices are allowed to initiate episodes. BPCI Advanced will initially include 29 Inpatient Clinical codes. and three Outpatient Clinical codes. Applications are due March 12, 2018.

Eligible Participants A BPCI Advanced participant is defined as an entity that enters into a participation agreement with CMS to participate in the model. There are two participant categories in BPCI Advanced: •

A Convener Participant brings together multiple downstream entities referred to as “Episode Initiators, facilitates coordination among them, and bears and apportions the financial risk.

•

A Non-Convener Participant on the other hand bears financial risk only for itself and does not bear financial 17

Table 1: Summary of the BPCI Advanced Model Clinical Episode: Acute care hospital inpatient stay or hospital outpatient procedure, plus post-acute care Episode Length: Anchor Stay (inpatient episode) or Anchor Procedure (outpatient episode) + 90 days following discharge Inpatient Clinical Episodes

1. Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis* *(New episode added to BPCI Advanced) 2. Acute myocardial infarction 3. Back and neck except spinal fusion 4. Cardiac arrhythmia 5. Cardiac defibrillator 6. Cardiac valve 7. Cellulitis 8. Cervical spinal fusion 9. COPD, bronchitis, asthma 10. Combined anterior posterior spinal fusion 11. Congestive heart failure 12. Coronary artery bypass graft 13. Double joint replacement of the lower extremity 14. Fractures of the femur and hip or pelvis 15. Gastrointestinal hemorrhage 16. Gastrointestinal obstruction 17. Hip and femur procedures except major joint 18. Lower extremity/humerus procedure except hip, foot, femur 19. Major bowel procedure 20. Major joint replacement of the lower extremity 21. Major joint replacement of the upper extremity 22. Pacemaker 23. Percutaneous coronary intervention 24. Renal failure 25. Sepsis 26. Simple pneumonia and respiratory infections 27. Spinal fusion (non-cervical) 28. Stroke 29. Urinary tract infection

Outpatient Clinical Episodes

1. Percutaneous coronary intervention (PCI) 2. Cardiac defibrillator 3. Back and neck except spinal fusion

• Payment from CMS, and Financial Reconciliation •

•

CMS will apply a 3 percent discount (percentage applied to the benchmark price to calculate the Target Price) in initial model years. Payments amounts derive from Medicare FFS payment with retrospective reconciliation based on comparing actual spending to the episode target price, and then adjusted for quality performance. Reconciliation will be a semi-annual process where CMS will compare the aggregate Medicare FFS expenditures for all items and services included in a Clinical Episode against the Target Price for that Clinical Episode to determine whether the Participant is eligible to receive a payment from CMS, or is required to pay a Repayment Amount to CMS.

risk on behalf of multiple downstream Episode Initiators. Only acute care hospitals and physician group practices PGPs can be episode initiators in BPCI Advanced. Other entities, such as post-acute care providers, can participate as a convener of downstream Episode Initiators and assume the associated risk. BPCI Advanced does not have any models that initiates with the PAC period. Quality Measures In the first two model years, participants will be responsible for up to seven claimsbased quality measures, as applicable. The table below lists the seven quality measures selected by CMS at this time. In future years, participants may be responsible for additional claims-based quality measures, or may have to report on additional nonclaims-based measures. Post-Acute Care In an FAQ document accompanying the announcement, CMS discussed why there is not version of BPCI Advanced that initiates with the post-acute period. The agency’s response states: “During development of the next generation episode payment model, we sought to build upon the successes of the BPCI initiative Models 2 (includes inpatient stay) and 3 (initiates with post-acute services). We knew that the next generation episode payment model would require a welldeveloped risk-adjusted prospective pricing mechanism, would be an Advanced APM, and, as such, would require payments be tied to quality. We also wanted model pricing to recognize and not penalize the efficiency achievements of current BPCI participants. Incorporating all of this into a pricing approach proved challenging. We concentrated our efforts on Clinical Episodes that include the inpatient stay. Finally, BPCI evaluation findings (see third annual report) also suggested that in Model 3, there were significant shifts in patientmix for some of the clinical episodes. Findings raised the possibility that some of these patient mix shifts may not be adequately captured by the claims data which the risk adjustment will rely on. AMRPA Magazine February 2018

Table 2: Summary of BPCI Participants’ Roles BPCI Advanced Participant Types

Eligible Entities

Non-Convener Participant

•

Acute care hospitals

•

Bears financial risk only on behalf of itself, and not on behalf of multiple downstream entities

•

Physician group practices

•

Must be an Episode Initiator

Convener Participant

•

Acute care hospitals

•

Brings together multiple downstream entities, referred to as Episode Initiators

•

Physician group practices

•

Bears and apportions financial risk

•

Facilitates coordination among its Episode Initiators (either acute care hospitals and/or PGPs)

Eligible entities that are Medicare-enrolled providers or suppliers

•

Eligible entities that are not enrolled in Medicare

Table 3: Quality Measures Used in Evaluating Performance in BPCI Advanced Required for All Clinical Episodes 1. All-cause Hospital Readmission Measure (NQF #1789) 2. Advanced Care Plan (NQF #0326) Applies Only to Select Clinical Episodes

At this time, there are no plans for a model that initiates with delivery of post-acute services. CMMI continues to explore episode payment models for Post-Acute as well as other Medicare services and is always interested in stakeholder input. We also are interested in a model in the post-acute space that could support the IMPACT Act of 2014 goal of payment reform for post-acute services.” Resources More information about the model, its requirements and application instructions can be found on CMS’ BPCI Advanced website. The application and required documents must be submitted via the BPCI Advanced Application Portal by March 12, 2018, at 11:59 pm EST. Questions regarding the BPCI Advanced Model can be directed to BPCIAdvanced@cms.hhs. gov.

3. Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268) 4. Hospital-level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550) 5. Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558) 6. Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881) 7. AHRQ Patient Safety Indicators (PSI 90) Model Timeline

Source: CMS 19

OFFICE OF THE ACTUARY RELEASES 2016 NATIONAL HEALTH EXPENDITURES

.S. health care spending increased 4.3 percent to reach $3.3 trillion, or $10,348 per person in 2016 according to a report issued by the Centers for Medicare and Medicaid Servicesâ&#x20AC;&#x2122; (CMS) Office of the Actuary in early January. Health care spending growth decelerated in 2016 after the initial impacts of coverage expansions under the Affordable Care Act (ACA) and strong retail prescription drug spending growth in 2014 and 2015. The overall share of gross domestic product (GDP) related to health care spending was 17.9 percent in 2016, up from 17.7 percent in 2015.

The charts below provides an overview of health care spending by type of service and funding. Health Spending by Type of Service or Product

Health Spending by Major Source of Funds

Hospital Care (32 percent share)

Medicare (20 percent share)

Spending for hospital care increased 4.7 percent to $1.1trillion in 2016, slower than the 5.7 percent growth in 2015 and was driven by the slower growth in the use and intensity of services. Hospital care expenditures showed mixed trends across the major payers, with slower growth in Medicaid and private health insurance spending, stable growth in Medicare spending, and faster growth in out-ofpocket spending.

Medicare spending grew 3.6 percent to $672.1 billion in 2016, which was lower than growth in the previous two years when spending increased 4.8 percent in 2015 and 4.9 percent in 2014. The slower growth in 2016 was due to slower growth in spending for both the Medicare fee-for-service (2.2 percent in 2015 to 1.8 percent in 2016) and Medicare Advantage (11.1 percent in 2015 to 7.4 percent in 2016) portions of Medicare.

Physician and Clinical Services (20 percent share) Spending on physician and clinical services increased 5.4 percent to $664.9 billion in 2016. Although growth for physician and clinical services decelerated slightly in 2016 from the (5.9 percent in 2015), it outpaced the growth in all other goods and services categories. The growth in the use and intensity of physician and clinical services was a driving factor in the overall growth in physician and clinical services, accounting for nearly three-quarters of the 5.4 percent increase. Home Health Care (3 percent share) Spending for freestanding home health care agencies (HHAs) decelerated in 2016, increasing 4.0 percent to $92.4 billion from 5.8 percent growth in 2015. Slower growth in Medicaid spending (4.6 percent in 2016 from 7.7 percent in 2015), out- of pocket spending (0.5 percent in 2016 from 3.1 percent in 2015) and private health insurance spending (2.8 percent in 2016 from 6.6 percent in 2015) contributed to slower overall growth in 2016. Medicare and Medicaid together made up 77 percent of home health spending in 2016. Nursing Care Facilities and Continuing Care Retirement Communities (5 percent share) Spending for freestanding nursing care facilities and continuing care retirement communities decelerated in 2016, growing 2.9 percent to $162.7 billion, compared to 3.7 percent growth in 2015. The slower growth in 2016 was largely attributed to slower spending growth in both Medicare (1.2 percent in 2016 from 4.0 percent in 2015) and private health insurance (5.9 percent in 2016 from 14.3 percent in 2015). Durable Medical Equipment (2 percent share) Retail spending for durable medical equipment (DME), which includes items such as contact lenses, eyeglasses and hearing aids, reached $51.0 billion in 2016 and increased 4.9 percent, which was faster than the 4.1 percent growth in 2015.

Medicaid (17 percent share) Total Medicaid spending decelerated in 2016, increasing 3.9 percent to $565.5 billion. This was much slower growth than in the previous two years, when Medicaid spending grew 11.5 percent in 2014 and 9.5 percent in 2015. The stronger growth in 2014 and 2015 was due in part to the initial impacts of the ACAâ&#x20AC;&#x2122;s expansion of Medicaid enrollment during that period. State and local Medicaid expenditures grew 3.2 percent, while federal Medicaid expenditures increased 4.4 percent in 2016. Private Health Insurance (34 percent share) Private health insurance spending increased 5.1percent to $1.1 trillion in 2016, which was slower than the 6.9 percent growth in 2015. The deceleration was largely driven by slower enrollment growth in 2016 after two years of robust enrollment growth due in part to ACA coverage expansion. Out-of-Pocket (11 percent share) Out-of-pocket spending grew 3.9 percent in 2016 to $352.5 billion, faster than the growth of 2.8 percent in 2015. This was the fastest rate of growth since 2007 and exceeded the average annual of growth 2.0 percent from 2008-15.

Physician and Clinical Services (20 percent share): Spending on physician and clinical services increased 5.4 percent to $664.9 billion in 2016. Although growth for physician and clinical services decelerated slightly in 2016 from the (5.9 percent in 2015), it outpaced the growth in all other goods and services categories. The growth in the use and intensity of physician and clinical services was a driving factor in the overall growth in physician and clinical services, accounting for nearly three-quarters of the 5.4 percent increase. 20

AMRPA Magazine February 2018

AMRPA RESPONDS TO MEDPAC’S DRAFT RECOMMENDATION OF FIVE PERCENT REDUCTION FOR IRFS Editor’s Note: On January 8, 2018, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Medicare Payment Advisory Commission (MedPAC) urging rejection of its draft recommendation of a five percent payment reduction for inpatient rehabilitation facilities (IRFs) for fiscal year (FY) 2019. The complete letter is provided below and is available on the www.amrpa.org website. January 8, 2018 Francis J. Crosson, M.D., Chairman Medicare Payment Advisory Commission 425 Eye Street, NW, Suite 701 Washington, DC 20001 Re: American Medical Rehabilitation Providers Association’s Comments on Chairman’s Draft Recommendation Regarding Inpatient Rehabilitation Facilities for Fiscal Year 2019

his letter is submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) to provide our comments on the Chairman’s draft recommendations relating to Medicare payments for inpatient rehabilitation facilities (IRFs) and specifically to urge its rejection.

AMRPA is the national voluntary trade association representing more than 600 freestanding rehabilitation hospitals, rehabilitation units of general hospitals, and outpatient rehabilitation service providers. Our members provide medical rehabilitation services in a vast array of health care settings working with patients to maximize their health, functional skills, independence, and participation in society so they are able to live as independently as possible by returning home, returning to work or, in many instances, pursuing an active retirement. On average Medicare Part A payments represent more than 60 percent of IRFs’ revenues. Proposals to Stack Recommendations Of primary concern to AMRPA is MedPAC’s apparent decision to stack additional post-acute care recommendations on top of prior Commission recommendations, whose problems were previously flagged but ultimately ignored by MedPAC. The unintended consequences from the concurrent application of problematic policy recommendations jeopardize both patient access to care and the financial viability of inpatient rehabilitation providers. PAC PPS Blended Rates While we support post-acute care (PAC) payment system reform, this proposal would prematurely expedite provider transition towards a unified PAC PPS. To generate payments that reflect the current cost of providing PAC services, the model’s underlying cost data must

align with the actual cost of care. Yet the MedPAC prototype relies on cost data from 2008-2010 Medicare claims data, and used a provider sample from 2013 that neither reflects the national PAC provider distribution nor captures the full array of PAC patients. Therefore, the data used in MedPAC’s PAC PPS prototype contains foundational problems making it unworkable as an actual payment model. Moreover, this proposal circumvents what Congress envisioned in passing the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. The Act was enacted to standardize patient assessment, outcomes and resource use data across different PAC providers to obtain a more complete understanding of quality as a precursor to evidence-based payment reforms. AMRPA remains committed to seeing the IMPACT Act fully implemented so that reforms are built on top of the evidentiary base it was designed to create. AMRPA is troubled by MedPAC’s lack of transparency in considering a draft recommendation to base Post-Acute Care (PAC) payments on a blend of setting-specific relative weights and the unified PAC Prospective Payment System (PPS) relative weights beginning in 2019. Key details regarding the methodology and underlying data for this proposal have not been made available to the public. Specifically, the public has not been informed of what the actual relative weights would be, how these rates would be set, or how they would differ from the setting-specific weights under current PPSs. Without access to the same information available to the Commissioners, MedPAC is effectively precluding stakeholders from providing meaningful feedback to properly assess the merits and implications of this proposal before a final determination is made. Medicare Margins The Commission’s findings indicate that aggregate Medicare margins among inpatient rehabilitation providers remain adequate. Yet as we have previously noted, MedPAC’s overreliance on aggregate margins obfuscates the range of margins among IRFs. MedPAC’s analysis reveals that most IRFs do not have significant margins. The clear majority of IRFs are hospital-based rehabilitation units (77 percent) that have an aggregate margin of 1.2 percent. Additionally, a substantial majority of IRFs are also nonprofit (57 percent) with aggregate margins of 2.0 percent. The Chairman’s draft recommendation of a 5 percent payment reduction to the IRF Prospective Payment System (PPS) base rate runs the risk of severe adverse effects for many providers and their patients. AMRPA is particularly concerned that MedPAC has not revised its rationale or impact analysis of a 5 percent cut in light of its inaccurate forecast of the 2016 aggregate IRF margin. MedPAC’s projected 2016 aggregate IRF margin (13.9 percent) overestimated the actual 2016 margin by nearly a full percentage point. Despite having projected 2016 margins to increase, MedPAC’s recent data indicate that 21

Medicare margins declined for all IRF types in 2016. In addition to the Medicare data relied on by the Commission, the IRF PPS FY 2018 rate setting files reveal additional pertinent findings about the adequacy of Medicare payments to IRFs. Our analysis found that for FY 2018:4 •

43 percent of IRFs will have negative Medicare margins (below 0 percent), and 65 percent of all rural IRFs will have negative Medicare margins;

•

52 percent of all IRFs will have margins below 5.0 percent;

•

More than two-thirds of IRFs (64 percent) will have Medicare margins below 11.9 percent, MedPAC’s aggregate Medicare margin for all IRFs in FY 2019; and The median Medicare margin for all IRFs will be 3.3 percent.

In analyzing payment versus cost as a definition of margins, it is clear that a 5 percent payment cut would have dramatic consequences for the majority of IRFs. Given that the median margin for IRFs is 3.3 percent, an aggregate 5 percent cut to the payment system is unduly harmful to more vulnerable providers due to the wide variations in margins at the individual provider level. In analyzing payment versus cost as a definition of margins, it is clear that a 5 percent payment cut would have dramatic consequences for the majority of IRFs. Given that the median margin for IRFs is 3.3 percent, an aggregate 5 percent cut to the payment system is unduly harmful to more vulnerable providers due to the wide variations in margins at the individual provider level. Focused Medical Record Reviews MedPAC recommends that the Secretary conduct focused medical reviews to assess inter-rater reliability across IRFs variability in IRF assessment practices. However, the Commission seems decidedly focused on penalizing the more profitable subset of the provider community rather than identifying ways to facilitate greater efficiencies among less profitable providers while preserving access for the most medically complex patients. While AMRPA shares MedPAC’s desire to better understand the factors underlying variation in Medicare margins, we remain troubled by the continued suggestion that strong margins are due to coding or patient selection. For example, MedPAC seems to presume that more profitable IRFs are selecting more patients with specific conditions like stroke without paralysis. Selecting IRFs to review based on profitability, as opposed to payment and costs, inherently scrutinizes providers that have found ways to be efficient in resource utilization. As structured, such reviews risk mistaking correlation for causation and assume a unidirectional relationship despite the lack of support for that assumption. AMRPA appreciates that MedPAC staff seek to gain a better understanding of Functional Independence Measure (FIM™) scoring at the clinical level. However, any medical record review conducted by CMS should only be used to assess inter-rater reliability for qualitative research purposes and not linked to payment denials or recoupments. Piling onto the completely overwhelmed audit program that IRFs already face threatens to add additional cost burdens on providers and the system at large without corresponding and potentially beneficial changes to practices or policies. Further, without evidence 22

that MedPAC’s IRF margin quintiles remain constant from year-toyear, the analysis should not trigger policy responses to what may be fleeting and otherwise arbitrary categories. IRF Outlier Pool Expansion AMRPA does not believe that expanding the outlier pool is the solution to margin variability or otherwise adequate to offset the tremendous harm that a 5 percent reduction in Medicare payments would inflict. There may be multiple reasons for outlier cases: complex patents known at admission, patients who developed unforeseen costly problems, higher cost structures and other factors. These factors suggest that expanding the outlier pool would not achieve MedPAC’s intended policy objectives of increasing outlier payments for the costliest cases while easing the burden for IRFs with a relatively large number of such cases. As we have previously cautioned, outlier payments are not a general policy that should be used to arbitrarily redistribute funds within the IRF sector, nor could they be reliably employed in this way. Moreover, as MedPAC is aware, the outlier payment policy is a budgetneutral program, such that increasing total outlier payments would further decrease the PPS base rate in addition to the reduction the Commission is considering. Moreover, given the prospective nature of the outlier payment methodology, outlier payments have consistently resulted in a net loss that has taken money out of the IRF PPS system in recent years. This is certainly the case for individual IRFs that, despite their high costs, have fewer than average outlier cases. For these reasons, expanding the amount of the outlier pool further risks reducing reimbursement for those IRFs that can least afford it. While AMRPA is eager to discuss with CMS and MedPAC potential ways to improve the effectiveness of the outlier pool policy, we simply do not feel this is a viable approach to mitigate the harm of an excessive payment reduction. Conclusion MedPAC asserts that its proposed 5 percent cut would be mitigated by combining it with additional proposals to expand the high-cost outlier pool and incorporate blended rates derived from the PAC PPS. Unfortunately, these mitigating factors are more likely to become a series of compounding calamities. Simply stacking unproven and problematic recommendations on top of an inherently flawed across-the-board payment cut will not accomplish our shared goal of establishing meaningful reforms to Medicare payment policies for post-acute care. Once again, AMRPA appreciates the opportunity to provide the Commissioners with our comments on the important work you do. We welcome the opportunity to provide additional input throughout the process and to clarify any comments in this letter. If you have questions, please do not hesitate to contact Carolyn Zollar, AMRPA’s Executive Vice President of Government Relations and Policy Development at (202) 223-1920 or czollar@amrpa.org, or Martha Kendrick, AMRPA’s Washington Counsel at (202) 887-4215 or mkendrick@akingump.com. Sincerely,

Richard Kathrins, PhD Chair, AMRPA Board of Directors Chief Executive Officer, Bacharach Institute for Rehabilitation AMRPA Magazine February 2018

AMRPA KICKS OFF 2018 FEDERAL ELECTION CENTER

ith so many changes coming out of Washington these days, it’s more important than ever that AMRPA members stay involved in determining their representation in Congress. That’s why AMRPA is happy to announce a new civic engagement series that will provide information about upcoming Congressional primary elections leading up to the general election in November. In the coming months, these updates will appear in AMRPA Magazine, in our membership e-newsletter, Off the Record, and on the AMRPA website. As part of this civic engagement series, AMRPA will provide AMRPA members information on where and when state primaries are taking place, background on incumbent members of Congress, and resources, such as talking points on medical rehabilitation to discuss with candidates. These tools and our collective outreach efforts will help ensure that the medical rehabilitation field remains an important constituency for our elected representatives. In 2018, 33 seats in the Senate and all 435 seats in the House of Representatives are up for election. The first primaries will begin in March, and continue until November with the general election taking place in most states on November 6, 2018. Below please find information on the primary elections taking place in March, and find the list of Senators up for reelection in 2018. For further information please visit amrpa.org to view the ‘Congressional Elections’ page under the ‘Advocacy’ tab, and keep an eye out for more updates in future editions of the AMRPA Magazine and in Off the Record. If you have any questions or feedback, please contact Catherine Beal at cbeal@amrpa.org or +1-202-223-1920.

Find Your Representatives: Find your House representative here: www.house.gov/representatives/ find-your-representative and senators here: www.senate.gov/general/ contact_information/senators_cfm.cfm. For more information, and to find out if you are registered to vote, visit: www.usa.gov/voting. March Primaries: Texas – March 5, 2018 36 House seats are up for election. 28 incumbents and 8 vacant seats. Representative Joe Barton (R), Representative Blake Farenthold (R), Representative Gene Green (D), Representative Jeb Hensarling (R), Representative Sam Johnson (R), Representative Ted Poe (R) and Representative Lamar Smith (R) have decided not to seek reelection and Current Representative Beto O'Rourke (D) will be running for a seat in the Senate. Incumbent Sen. Ted Cruz (R) will be running for reelection. Illinois – March 20, 2018 18 House seats are up for election. 17 incumbents and 1 vacant seat. Representative Luis Gutiérrez (D) has decided not to seek reelection. No Senate seats are up for election. See page 24 for a complete list of House and Senate seats up for election in 2018.

Senators Up for Reelection: State

Incumbent

Party

Term

Membership on Senate Health Care Related Committees (In relation to AMRPA)

Dianne Feinstein

Democratic

5th

Chris Murphy

Democratic

1st

Senate Committee on Health, Education, Labor, and Pensions

Tom Carper

Democratic

3rd

Committee on Finance

Bill Nelson

Democratic

3rd

Committee on Finance

Mazie Hirono

Democratic

1st

Committee on Veterans' Affairs

Joe Donnelly

Democratic

1st

Elizabeth Warren

Democratic

1st

Committee on Health, Education, Labor, and Pensions

Ben Cardin

Democratic

2nd

Committee on Finance

Angus King

Independent

1st

Debbie Stabenow

Democratic

3rd

Amy Klobuchar

Democratic

2nd

Claire McCaskill

Democratic

2nd

Roger Wicker

Republican

2nd

Jon Tester

Democratic

2nd

Heidi Heitkamp

Democratic

1st

Deb Fischer

Republican

1st

Bob Menendez

Democratic

3rd

Martin Heinrich

Democratic

1st

Dean Heller

Republican

2nd

Kirsten Gillibrand

Democratic

2nd

Sherrod Brown

Democratic

2nd

Committee on Finance Committee on Finance Committee on Veterans' Affairs

Committee on Finance Committee on Finance Committee on Veterans' Affairs Committee on Finance Committee on Veterans' Affairs

Bob Casey

Democratic

2nd

Committee on Finance Committee on Health, Education, Labor, and Pensions

Sheldon Whitehouse

Democratic

2nd

Committee on Finance

Ted Cruz

Republican

1st

Tim Kaine

Democratic

1st

Committee on Health, Education, Labor, and Pensions

Bernie Sanders

Independent

2nd

Committee on Veterans' Affairs Committee on Health, Education, Labor, and Pensions

Maria Cantwell

Democratic

3rd

Committee on Finance

Tammy Baldwin

Democratic

1st

Committee on Health, Education, Labor, and Pensions

Joe Manchin

Democratic

2nd

Committee on Veterans' Affairs

John Barrasso

Republican

2nd

Senators Not Running for Reelection: State

Incumbent

Party

Term

Jeff Flake

Republican

1st

Bob Corker

Republican

2nd

Orrin Hatch

Republican

7th

Membership on Senate Health Care Related Committees (In relation to AMRPA)

Committee on Finance Committee on Health, Education, Labor, and Pensions

AMRPA Magazine February 2018

NEW DATA SUBMISSION SYSTEM ANNOUNCED FOR CLINICIANS IN THE QUALITY PAYMENT PROGRAM

he Centers for Medicare and Medicaid Services (CMS) launched a new streamlined online portal for doctors and other eligible clinicians participating in the Quality Payment Program (QPP) to submit their 2017 performance data. The portal can be found on the QPP website (qpp.cms.gov/). The data submission system is an improvement from the former systems that required clinicians to submit data on multiple websites. Now, eligible Medicare Part B clinicians will use the new system to submit their performance data for the QPP during the 2017 submission period, which runs from January 2, 2018, to March 31, 2018, for most eligible clinicians. As data is entered into the system, eligible clinicians will see real-time initial scoring within each of the Merit-based Incentive

Payment System (MIPS) performance categories. This scoring may change if new data is reported or quality measures that have not yet been benchmarked are used. Additionally, the performance category score will not initially take into account the user’s Alternative Payment Model (APM) status, Qualifying APM Participant (QP) status, or other special status that may apply to clinicians. There are multiple data submission options, including Qualified Clinical Data Registries (QCDRs), qualified registries, attestation or the CMS Web Interface. Eligible clinicians can also submit data using a Health IT Vendor, which extracts data from certified EHR technology. Clinicians can also generate a non-certified report in either the new QPP file format or QRDA III file format and manually upload the file into the submission system.

Highlight: •

Eligible clinicians can now use one website to submit their performance data to meet requirements of CMS’ Quality Payment Program.

The data can be updated at any time during the submission period. Once the submission period closes on March 31, 2018 (with the exception of the CMS Web Interface, which ends on March 16, 2018), CMS will calculate participating clinicians’ payment adjustment based on their last submission or submission update.

CMS ADDRESSES IMPROPER DISCHARGES FROM NURSING HOMES

ederal regulations governing long-term care (LTC) facilities allow facilities to initiate discharges of residents only in specific instances. Nonetheless, discharges that violate these regulations continue to be one of the most frequent complaints made to state long-term care ombudsman programs. A December 22 memorandum from the director of the Survey and Certification Group at the Centers for Medicare and Medicaid Services (CMS) to State Survey Agency Directors announced an initiative to examine and mitigate facilityinitiated discharges that violate federal regulations, effective immediately.

Facility Initiated Discharges/Evictions Federal LTC regulations provide protections for all nursing home residents, including the right to remain in the facility unless a limited set of circumstances apply. Improper discharges that violate these rules are of great concern because in some cases they are unsafe and/or traumatic for residents and their families.

These discharges may result in: •

Residents being uprooted from familiar settings;

•

Termination of relationships with staff and other residents;

•

Residents may even be relocated long distances away, resulting in fewer visits from family and friends and isolation of the resident.

•

In some cases, residents have become homeless or remain in hospitals for months.

The reasons for non-compliant discharges varied, according to CMS: •

Some discharges were driven by payment concerns, such as when Medicare or private pay residents shift to Medicaid.

•

The most commonly reported reason that residents are discharged is due to behavioral, mental and/or emotional expressions or indications of resident distress.

•

Sometimes LTC facilities discharge residents while the resident is hospitalized for health concerns unrelated to the behaviors that form the alleged basis for the discharge.

CMS will evaluate these and consider a variety of interventions such as surveyor and provider training, intake and triage training, as well as Civil Money Penalty (CMP) funded projects that may help prevent facility initiated discharges that violate federal regulations, and enforcement. CMS is also directing State survey agencies to transfer any case involving facility-initiated discharge violations to the CMS Regional Office for review in instances the resident placement is questionable or unsafe, where residents remain hospitalized, where there is a facility pattern, or other circumstances that the RO may identify of cases they would like transferred. The memo, “An Initiative to Address Facility Initiated Discharges that Violate Federal Regulations,” is available at www.cms.gov.

AMRPA Magazine February 2018

CMS ISSUES ADVANCE NOTICE ON PROPOSED CHANGES TO MEDICARE ADVANTAGE RISK ADJUSTMENT MODEL

n December 27, 2017, the Centers for Medicare and Medicaid Services (CMS) released Part I of the 2019 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part D Payment Policies (the Advance Notice). The notice proposes updates to the MA Risk Adjustment Model and the use of encounter data. The 2019 Advance Notice is being published in two parts due to requirements in the 21st Century Cures Act, which mandated certain changes to the MA, or Part C, risk adjustment model and a 60-day comment period for these changes. Changes to other payment methodologies proposed for the following calendar year that are typically contained in the Advance Notice only require a 30day comment period and will be released in accordance with that statutory deadline. The payment policies for 2019, proposed in both in Part I and Part II of the Advance Notice are to be finalized in the annual Rate Announcement. MA Risk Adjustment Model Proposal The 21st Century Cures Act amended the Social Security Act by, in part, requiring CMS to make improvements to risk adjustment for 2019 and subsequent years. In response to these requirements, CMS proposes changes to the CMS-HCC Risk Adjustment model that is used to pay for aged and disabled beneficiaries enrolled in Medicare Advantage plans. These proposals reflect changes to risk adjustment required by the 21st Century Cures Act, including an evaluation of adding mental health, substance use disorder and chronic kidney disease conditions to the risk adjustment model and making adjustments to take into account the number of conditions an individual beneficiary may have, as well as a variety of additional technical updates. Further, the Act requires that CMS fully phase in the required changes to the risk adjustment model by 2022. CMS proposes to begin the phase in of this new model in 2019, starting with a blend of 75 percent of the risk adjustment model used for payment

in 2017 and 2018 and 25 percent of the new risk adjustment model proposed. In the Novice, CMS outlines a proposed new risk adjustment model and also discusses an alternative model. The model it is proposing – the Payment Condition Count Model – takes into account the conditions that a beneficiary has of the conditions that are used in the payment model. The model discussed as an alternative – the All Condition Count Model – takes into account all conditions that a beneficiary has, including both those in the payment model and those not in the model. Overall, while the experience of individual plans would vary, the Payment Condition Count model is projected to increase MA risk scores by 1.1 percent, while the All Condition Count model would decrease MA risk scores by -0.28 percent. The Payment Condition Count model generates more consistent and generally positive changes in MA contracts’ risk scores, whereas the All Condition Count model results in more varied scores with both negative and positive changes. CMS payments to MA plans are reflective of a beneficiary’s level of sickness, with sicker patients having higher risk scores. Accordingly, MA plans with higher risk scores will receive higher payments from the government. Using Encounter Data The model that CMS proposes also makes technical updates that include: •

Calibrating the model with more recent data;

•

Selecting diagnoses with the same method used for encounter data; and

•

Supplementing encounter data used in payment with inpatient data submitted to the historical risk adjustment data collection system (the Risk Adjustment Processing System [RAPS]).

CMS calculates risk scores using diagnoses submitted by Medicare fee-for-service (FFS) providers and by MA organizations. Historically, CMS has used diagnoses

Highlight: •

For 2019, CMS is proposing a model that includes additional mental health, substance use disorder and chronic kidney disease conditions in the risk adjustment model.

submitted into RAPS by MA organizations. In recent years, CMS began collecting encounter data from MA organizations, which is the MA equivalent of FFS claims data and contains diagnostic information. •

In 2016, CMS began using diagnoses from encounter data to calculate risk scores, by blending 10 percent of the encounter data-based risk scores with 90 percent of the RAPS-based risk scores.

•

For 2017 and 2018, CMS continued to use a blend to calculate risk scores, by calculating risk scores with 25 percent encounter data and 75 percent RAPS in 2017, and 15 percent encounter data and 85 percent RAPS in 2018.

•

For 2019, CMS proposes to calculate risk scores by adding 25 percent of the risk score calculated using diagnoses from encounter data and FFS diagnoses with 75 percent of the risk score calculated with diagnoses from RAPS and FFS diagnoses. CMS is also proposing to implement the phase-in of the new risk adjustment model by calculating the encounter data-based risk scores exclusively with the new risk adjustment model, while maintaining use of the current 2018 risk adjustment model for calculating risk scores with RAPS data.

Comments on Part I of the proposed Advance Notice must be submitted by March 2, 2018. The final 2019 Rate Announcement will be published by April 2, 2019.

CMS ISSUES NEW IRF COVERAGE REQUIREMENT DOCUMENTS; AMRPA SEEKS PROVIDER FEEDBACK

he Centers for Medicare and Medicaid Services (CMS) recently announced a number of new documents pertaining to IRF (inpatient rehabilitation facility) coverage requirements. The first is a Medicare Learning Network (MLN) article, titled Inpatient Rehabilitation Facility (IRF) Medical Review Changes, that provides information about new instructions that CMS recently issued to Medicare review contractors regarding the standards to use when reviewing claims for compliance with the intensity of therapy requirements for IRF claims. The second document is a MLN booklet titled Inpatient Rehabilitation Facility (IRF) Reference Booklet. The booklet’s stated purpose is to provide education about common documentation errors, scenarios and solutions for IRF services as identified by CMS’ medical review contractors. The booklet goes through most parts of the Medicare IRF coverage requirements, and analyzes example scenarios to explain CMS’ standard for each requirement. This booklet was compiled by the A/B CERT Task Force, which is a compilation of representatives from different Medicare Administrative Contractors (MACs).

The third document is standard IRF denial reason codes and statements. CMS states they created these standardized denial reasons and codes because different contractors often used different codes and phrasing, and that by standardizing the codes CMS would lessen the burden on providers and allow for a better understanding of the reason for denial. Finally, CMS has also compiled all coverage requirement clarifications issued by CMS pertaining to IRF coverage requirements into one document. This document does not contain any new clarifications, but simply compiles previously issued clarifications in to one document. AMRPA is seeking feedback on these documents from AMRPA members. To view these documents, please go to www.AMRPA. org and click “New CMS IRF Coverage Documents” under the Advocacy tab at the top of the home page. Address your comments on these documents to Jonathan Gold, JD, AMRPA Regulatory and Government Relations Counsel at jgold@amrpa. org or phone him at +1-202-223-1920.

JOIN TODAY!

EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE AMRPA: Working Together to Preserve Access to Medical Rehabilitation Samantha Schwarz, AMRPA MemberTo Services Coordinator, 202-207-1132, sschwarz@amrpa.org AMRPA: Working Together Preserve Access To Medical Rehabilitation 28

Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org AMRPA Magazine February 2018

FOLLOW-UP PHONE CALLS INSTEAD OF FACE-TO-FACE VISITS A SUITABLE ALTERNATIVE FOR SOME PATIENTS, STUDY FINDS

he standard of care for hospital discharge planning includes arranging follow-up appointments, usually with a primary care provider. However, followup phone calls instead of face-to-face visits may be an appropriate alternative for some patients, according to a study published by the Joint Commission, “An Initiative to Change Inpatient Practice: Leveraging the Patient Medical Home for Postdischarge Follow-Up.” This option was explored within the framework of the Department of Veterans Affairs (VA) patient-centered medical home model of care, the Patient Aligned Care Team (PACT). The initiative was intended to transform the way veterans receive care by providing patient-driven, proactive, personalized, team-based care focused on wellness and disease prevention that would result in improved patient satisfaction and healthcare outcomes, and more efficient spending. The PACT model is built on the

well-known concept of the patient-centered medical home staffed by high-functioning teams. Three-Phase Pilot Study At a VA hospital, a pilot study was conducted on the use of phone calls from members of a patient's medical home as post-hospital discharge follow-up rather than the traditional face-to-face provider model. Inpatient providers were educated about the phone follow-up alternative, and this option was standardized as part of discharge planning rounds. •

During Phase 1 at one clinic over three months, 17 of 118 eligible patients received phone call followup (14.4 percent of discharges) instead of the traditional face-to-face follow-up.

•

During Phase 2, data from Phase 1 were analyzed, and staff at eight other clinic sites were trained.

•

The initiative was expanded to

all regional clinic sites in Phase 3. Seventy-six of 447 eligible discharges (17.0 percent) were scheduled for phone follow-up. With regard to patient outcomes postdischarge, results showed that there were not significant differences in the rates of 30day emergency department (ED) utilization (11.9 percent and 5.9 percent, (p = 0.47)) or non-elective rehospitalizations (16.8 percent and 17.6 percent, (p = 0.93)) between the cohort of patients who received follow-up calls versus those who received face-to-face visits. The study concluded that this initiative changed provider practices to use phone call follow-up for certain patients instead of face-to-face provider visits after hospital discharge, without significantly increasing rates of 30-day ED utilization or rehospitalization.

ADMINISTRATION FOR COMMUNITY LIVING ANNOUNCES NEW GRANTS FOR REHABILITATION RESEARCH AND TRAINING

he Administration for Community Living (ACL) National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) recently announced several funding opportunities for the Rehabilitation Research and Training Center (RRTC) Program. Created by the Department of Health and Human Services (HHS) in 2012, the ACL serves as the federal agency responsible for increasing access to community supports, while focusing attention and resources on the unique needs of older Americans and people with disabilities across the lifespan. The purpose of the RRTCs is to improve the effectiveness of services authorized under the Rehabilitation Act through research, training, technical assistance and dissemination activities. These activities are designed to benefit rehabilitation service providers, individuals with disabilities and other stakeholders. The funding opportunities are listed:

•

RRTC on Community Living and Participation for People with Serious Mental Illness The purpose is to contribute to improving the community living and participation outcomes of individuals with severe mental illness by conducting research activities and serving as a national resource center for training, technical assistance and dissemination.

•

RRTC on Disability in Rural Communities To generate new research-based knowledge that can be used to improve outcomes in one or more of the following outcome domains for people with disabilities living in rural communities: community living and participation, employment, and health and function.

•

RRTC on Disability Statistics and Demographics To conduct activities to advance the use and usefulness of disability statistics and demographic data to inform disability policies and practices

toward providing full opportunities and accommodations for individuals with disabilities. This includes analyzing disability-relevant nationally representative data, improving survey methods related to people with disabilities, conducting knowledge translation of findings, and creating and implementing a web-based platform for improved public access to data. •

RRTC on Promoting Healthy Aging for People with Long-term Physical Disabilities To generate new research-based knowledge on healthy aging for people with long-term physical disabilities, including evidence-based information on the management of secondary conditions, and practices, programs, and policies that promote healthy aging for this population.

The application deadline is February 20, 2018. The full announcement can be found on the ACL website.

AMRPA Magazine February 2018

CALL FOR ABSTRACTS & POSTERS Visit us at amrpa.org to submit your abstract! Deadline for submission is: April 15, 2017

PRESENT

Share your knowledge with the decision makers of the medical rehabilitation industry. Gain exposure for your professional career and organization.

NETWORK

Engage with colleagues in your field, develop new professional contacts, and build your interdisciplinary knowledge on a variety of key rehab topics.

BUILD YOUR CV

Add AMRPAâ&#x20AC;&#x2122;s name to your CV and learn new skills along the way.

TRACKS:

Business Operations and Leadership Development; Clinical Care Delivery: A Team Approach; Regulatory, Legislative, and Accreditation Matters; Marketing and Relationship Management; and Other 31

AMRPA Magazine February 2018