AMRPA Magazine January 2018

Januar y 2018 • Vol. 21, No. 1

MOVING IN A POSITIVE DIRECTION

Volume 21, Number 1

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

The Latest Developments in the Appeals Backlog Lawsuit: HHS’ Motion to Dismiss ..................................................................................... 8

Peter Thomas, JD Counsel to the AMRPA Consumer and Clinical Affairs Committee, Principal, Powers Pyles Sutter & Verville, PC Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-Advanced Outcomes Design Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA

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

2018: The Year of the PPS Coordinator........................................................... 12 Episode Payment Models and Cardiac Rehabilitation Incentive Programs Cancelled; Comprehensive Joint Repair Program Modified......................... 14 MedPAC to Vote on 5 Percent Payment Cut for IRFs in FY 2019 ................. 19 BPCI Year 3 Evaluation Results Show Savings for Joint Replacements but Mixed (to Disappointing) Quality Signals ................................................ 22

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

ARN Develops Tools as a Guide for Continence Care .................................. 26

Mimi Zhang Policy and Research Associate, AMRPA

CMS Compiles IRF Coverage Requirement Clarifications into One Document ......................................................................................... 26

Lovelyn Robinson Editorial and Research Assistant, AMRPA

CMS Announces 2018 Medicare Parts A and B Premiums and Deductibles .............................................................................. 27 CMS Releases Hospital Value-Based Purchasing Program Results for FY 2018 ........................................................................... 28

AMRPA Magazine, Volume 21, Number 1.

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

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

SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues.

Individuals who are employees of member institutions may subscribe to the magazine for $100 annually. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th Street, NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1500; Half page = $1000; Third page = $750. Ads may be B&W or full color. Contact Ryan Foster, rfoster@kellencompany.com for additional specs and acceptable submission format.

Advertising Contact: Samantha Schwarz, AMRPA, 529 14th Street, NW, Washington, DC 20045 USA, Phone: +1-202207-1132, Email: sschwarz@amrpa.org

Grant Awarded to Promote Exercise and Health Among Persons with Disabilities ......................................................... 29 HHS’ Leaning and Action Network Issues Second Report on APM Adoption Rates ................................................................................. 30 Implantable Muscle Stimulator Device Aims to Benefit Patients with Spinal Cord Injuries ....................................................... 32 Challenges Remain in the Collection of Medicare Overpayments by ZPICs and PSCs, OIG Says ................................................ 33 Study Examines the Association of the Hospital Readmissions Reduction Program with Readmission and Mortality Outcomes in Heart Failure ......... 35 AMRPA Submits Feedback on CMMI’s New Direction to Transform Health Care Delivery ...................................................................... 36 2018 AMRPA Board of Directors ..................................................................... 42

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 ©2017

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

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AMRPA Magazine January 2018

LETTER FROM THE CHAIR

Letter from the Chair Richard Kathrins, PhD, CEO, Bacharach Institute for Rehabilitation RKathrins@bacharach.org

Moving in a Positive Direction

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ver the last four years Dr. Gans has worked tirelessly to address the many challenges facing our field.

Under his leadership we have made great strides in developing innovative and progressive ideas to position the medical rehabilitation field for the future. We are all very thankful for Dr. Gans’ contributions to our association.

As incoming Chair of the Board, I am committed to our association’s mission in guiding our efforts. Our mission states, “AMRPA is the nation’s only trade organization dedicated solely to the interests of Inpatient Rehabilitation Hospitals and Units (IRH/U), outpatient rehabilitation centers and other medical rehabilitation providers with a focus on collective advocacy to advance the field of medical rehabilitation and support the medical rehabilitation needs of persons with disabilities.”

In my new role, I look forward to working with our members to keep the AMRPA’s momentum moving in a positive direction. We will continue to work for a stable environment that will allow us to effectively serve the patients and families in our communities. We will also work to continue to be recognized as the champions of medical rehabilitation in order to best serve the public.

These challenges include better alignment of our payment system with evidence-based care, reducing regulatory burdens on our providers such as the 60% Rule, audits, appeals and therapy caps, ensured patient access and coverage, and restoring payment cuts.

These challenges will remain a priority.

AMRPA is composed of members with a wealth of talent. We have many voices within our association and we need to be responsive to the collective good, as well as individual needs. One of the best ways to ensure broad representation is for you to get involved.

Many committees and work groups need members who can share their clinical, administrative and financial expertise. Many of these committees are listed on our webpage under the About Us tab.

If you are willing to get involved, contact our Washington office +1-202-223-1920 and give your name to Catherine Beal (cbeal@ amrpa.org). We can’t represent your interests, concerns or ideas if you remain on the sidelines.

On behalf of the AMRPA leadership, we look forward to working with you and your team. If you would like to talk to me directly, please do not hesitate to reach out (+1-609-412-1169 – mobile phone). We have a strong association and with your actions and support we will remain strong, relevant and progressive. Thank you for your involvement and ongoing commitment to our mission.

Our association’s leadership is committed to addressing the many challenges that remain and those that may present themselves.

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AMRPA LEGISLATIVE UPDATE

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

Tax Reform Package Goes to Conference

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n Dec. 4, 2017, the House voted 222-192 to go to Conference with the Senate on tax reform legislation, and the Senate followed suit with a 51-47 vote to go to Conference on Dec. 6. The Conference committee is expected to begin work soon, with the goal of delivering a final tax reform bill to the President by Christmas. Conferees include the following Members: Reps. Brady (RTX), Nunes (R-CA), Roskam (R-IL), Black (R-TN), Noem (R-SD), Neal (D-MA), Levin

•

• • • • •

There are several significant substantive differences between the House and Senate bills. The Senate version of the Tax Cuts and Jobs Act, passed on Dec. 2, would effectively eliminate the Affordable Care Act’s individual mandate. The House bill, passed on Nov. 16, would keep it. A

end passage of the Alexander-Murray market stabilization bill and her own $10 billion reinsurance proposal. Rep. Tom Cole (R-OK) has confirmed, however, that House Republicans will not support either measure.

FY 2018 Funding Continues with Series of Continuing Resolutions On Dec. 2, House Republicans released the text of a two-week Continuing Resolution (CR) through Dec. 22. The measure also includes a technical fix to support states

December is often the busiest time in Washington, and this year is no different as Congress races toward the year-end finish line. Many issues remain unresolved and must be addressed before Members can head back to their districts. The two most pressing issues are to wrap up tax reform and ensure funding the federal government beyond Dec. 22.

November witnessed quick action on Congressional Republicans’ efforts to pass the most comprehensive rewrite of the federal tax code in more than three decades, using the Budget Reconciliation process.

President Trump announces Alex Azar, a former pharmaceutical executive and HHS general counsel, as his choice to lead the Department of Health and Human Services.

Long-term CHIP funding and other Medicare extenders, including therapy caps, remain unresolved.

CMS finalized cancellation of expanding the mandatory joint replacement bundling program and the Cardiac Rehabilitation Incentive Payment Model.

The Ways and Means Committee released a legislative package that provides relief from several Affordable Care Act (ACA) taxes from going into effect, including the health insurance tax, medical device tax, and Cadillac tax.

(D-MI), and Doggett (D-TX) all serve on the House Ways and Means Committee; Reps.

Bishop (R-UT), Young (R-AK), and Grijalva (D-AZ) all serve on the House Energy and Natural Resources Committee; and Reps.

Upton (R-MI), Shimkus (R-IL), and Castor (D-FL) serve on the House Energy and Commerce Committee. In the Senate, the following Senators were named: Sens.

Hatch (R-UT), Enzi (R-WY), Murkowski (R4

AK), Cornyn (R-TX), Thune (R-SD), Portman (R-OH), Scott (SC), Toomey (R-PA), Wyden (D-OR), Sanders (I-VT), Murray (D-WA), Cantwell (D-WA), Stabenow (D-MI), Menendez (D-NJ) and Carper (D-DE).

reconciled bill is likely to strip out the mandate. Additionally, the House tax bill would repeal the deduction for medical expenses, while the Senate version would expand it and lower the threshold to 7.5 percent of income.

Meanwhile, Sen. Susan Collins (R-ME) has stated that her support for a final Conference bill is contingent on year-

running out of Children’s Health Insurance Program (CHIP) funds. Both chambers quickly passed the measure on Dec. 7.

Republicans believe that passing a twoweek CR will allow more time for a Budget deal and then another CR into January.

As we go to print, it is not entirely clear whether Democrats in the minority or frustrated Conservatives might thwart or delay a year-end package by using this AMRPA Magazine January 2018

must-pass deadline as leverage on other pressing matters, such as immigration issues tied to the Deferred Action for Childhood Arrivals (DACA).

Medicare Extenders Legislation Not Yet Resolved On Nov. 15, House Ways and Means Committee Chairman Kevin Brady (R-TX) and Ranking Member Richard Neal (DMA) announced a bipartisan agreement on expiring Medicare extenders, which includes the previously announced bipartisan, bicameral and tri-committee (House Energy and Commerce Committee, House Ways and Means Committee and the Senate Finance Committee) permanent therapy caps repeal policy proposal. The 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.

As of Dec. 12, legislative language has not been released and Medicare extender talks have recently stalled amongst the Committees of Jurisdiction. If an agreement can be realized before the current CR expires, a Medicare extender package will likely ride with the next CR into January. Pay-fors are likely the biggest hold-up for an agreement.

Of interest to AMRPA members, the House Ways and Means Committee package includes a straight five-year extension of the home health rural addon payment. The package also changes the home health payment to a 30-day unit of payment and creates a Technical Expert Panel (TEP) to develop a new home health case mix model by Jan. 1, 2020. The TEP would make recommendations and release a report by 2019. CMS would go through the regular rulemaking progress to implement any payment changes by 2020. The Committee included a home health market basket cut in 2020 that is expected to generate $3 billion in savings over 10 years. $1 billion will cover the five year rural add-on extension and $2 billion will help offset the full package. Additional regulatory relief policies may also be

included (such as face-to-face relief), but legislative text has yet to be released.

CHIP Funding and Potential Offsets Uncertain While the proposed two-week CR includes a technical fix that allows states to access additional reserve dollars for their CHIP programs, the measure does not authorize any new funding. Lawmakers anticipate including CHIP reauthorization in a yearend package later this month, though final agreement on offsets for roughly $8 billion measure is still unclear. The House passed a five-year extension of CHIP funding on Nov. 3, with all but 15 Democrats opposing the measure due to the offset provisions included. The Senate Finance Committee previously passed a five-year extension of CHIP in October on a bipartisan basis, but the bill did not specify any offsets. While advocates remain hopeful for a longerterm fix, there is some indication that Congress will only be able to pass a two year CHIP reauthorization since pay-fors remain politically difficult.

Veterans Affairs Committee Moves Ahead with Reform Legislation On Nov. 29, the Senate Veterans’ Affairs Committee approved the “Caring for Our Veterans Act,” which would sunset the current Veterans Choice Program 5

after Dec. 31, 2018, and establish a new Veterans Community Care Program to streamline and consolidate existing community-based care programs. The legislation also establishes new prompt payment requirements and expands veterans’ access to care in the community.

CMS Releases Medicare Parts A and D Proposed Rule On Nov. 16, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that revises the Medicare Advantage and Medicare Part D regulations in order to implement certain provisions of the Comprehensive Addiction and Recovery Act (CARA) and the 21st Century Cures Act. The proposed rule also addresses program integrity policies related to Medicare Advantage,

and uncontrollable circumstances, such as the major hurricanes in 2017. The rule also cancels the hip fracture and cardiac bundled payment and the Cardiac Rehabilitation Incentive Payment Model scheduled to begin on Jan. 1, 2018.

*** Legislative activity over the next several The House Veterans’ Affairs Committee weeks will intensify, as Congress continues postponed a vote in early November on to grapple with several “must pass” items the “VA Care in the Community Care,” before the upcoming holidays and the which would reform and extend existing end of 2017. We remain concerned that community-based care programs under as members look for last-minute the auspices of the Veterans offsets, potential post-acute Choice Program, while care cuts will drop out of the removing the current 30Congressional sky to be included day, 40-mile requirement to We urge AMRPA Members to in one of the moving vehicles, so give veterans more timely come to Washington, DC, to we must continue to be vigilant. access to community care.

We encourage you to contact Committee Chairman Phil Roe participate in AMRPA’s upcoming your members of Congress and (R-TN) pulled the bill while March 12-13 Spring Conference let them know your concerns awaiting a final score from the and Congressional Fly-In. and the impact such policies will Congressional Budget Office have on patients who need and (CBO). Democrats on the depend on rehabilitative care.

Committee said the bill would cost about $40 billion over five If Congress is unable to resolve several Medicare cost plan, Medicare Part D and years. outstanding health care issues, such the PACE programs; and clarifies program as CHIP reauthorization and Medicare requirements regarding treatment of President Trump Nominates Alex Azar extenders, we expect a very busy start Medicare Part A and Part B appeal as HHS Secretary to 2018. We urge AMRPA Members to rights related to premium adjustments.

On Nov. 13, President Trump announced come to Washington, DC, to participate Comments on the proposed rule are due that he would nominate former Eli Lilly in AMRPA’s upcoming March 12-13 Spring

by Jan. 16, 2018. executive Alex Azar to serve as Health and Conference and Congressional Fly-In. Human Services Secretary. Azar, who also Entitlement Reform appears to be part of CMS Issues Final Rule on CJR Model served as deputy secretary and general the 2018 Republican Agenda so it will be a Changes counsel at HHS during the George W. critical time to get in front of policymakers On Nov. 30, CMS released a final rule Bush administration, has aligned with the to discuss several important policy issues, that reduces the number of mandatory pharmaceutical industry’s stances on drug as well as value-based purchasing, geographic areas participating in pricing and has opposed drug importation. implementation of the IMPACT Act, and the Comprehensive Care for Joint Testifying before the Senate Health, issues related to managed care. Please Replacement (CJR) Model from 67 to 34; Education, Labor and Pensions (HELP) do not hesitate to reach out to me if you the list of participating areas is unchanged Committee on Nov. 29, Azar was pressed have any questions about the Fly-in and/or from the proposed rule issued in October.

by Democrats on his industry background.

AMRPA’s legislative priorities.

CMS also finalized a proposal to make The Senate Finance Committee has not participation voluntary for all low-volume yet scheduled a hearing to consider his and rural hospitals. An interim final rule nomination, but as we go to press, he is with comment period seeks comment expected to appear before the Committee on a final policy to provide flexibility for as early as late December. participant hospitals impacted by extreme

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AMRPA Magazine January 2018

COMPASSIONATE CARE , LEADING - EDGE TECHNOLOGY. Marianjoy Rehabilitation Hospital, now part of Northwestern Medicine, has been providing specialized programming for adults and children in the greater Chicagoland area for more than 40 years. With the 2016 opening of the Tellabs Center for Neurorehabilitation and Neuroplasticity, Marianjoy continues to advance research in the field of physical medicine and rehabilitation by delivering compassionate care coupled with leading-edge technology. Visit us at Marianjoy.org

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THE LATEST DEVELOPMENTS IN THE APPEALS BACKLOG LAWSUIT: HHS’ MOTION TO DISMISS

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recent filing in federal court sheds new light on the backlog of Administrative Law Judge (ALJ) appeals and makes public previously undisclosed efforts to settle with inpatient rehabilitation hospitals and units (IRH/ Us). On Nov. 3, 2017, the Department of Health and Human Services (HHS) filed a Motion for Summary Judgment in the American Hospital Association’s federal lawsuit seeking to compel HHS to reduce or eliminate the backlog at the ALJ level of administrative appeal. The plaintiff, the American Hospital Association (AHA), will file its motion on Dec. 20, 2017. HHS’s motion includes a wealth of information on the backlog and its efforts to reduce the wait for ALJ hearings and decisions.

plaintiff has a clear right to relief; 2) that the government official has a clear duty to act; and 3) that the plaintiff has no adequate alternative remedy. Once jurisdiction is established, however, a court usually must then weigh equitable factors for and against issuing the mandamus order.

most of these funds rightfully belong to the IRH/Us that provided care to Medicare beneficiaries. On Dec. 5, 2016, the district court granted a writ of mandamus and ordered HHS to clear the backlog by 30 percent per year and to completely eliminate it by the end of 2020.

AHA originally filed suit against HHS in 2014. In December 2014, the court dismissed AHA’s suit. AHA appealed to the DC Circuit Court of Appeals, where the Fund for Access to Inpatient Rehabilitation (FAIR Fund) filed an amicus curiae (“friend of the court”) brief in support of AHA. The FAIR Fund is a sister organization to the AMRPA. The DC Circuit reversed the district court and held that AHA satisfied the core jurisdictional requirements.

In early February 2017, HHS appealed to the DC Circuit Court. In August 2017, the Circuit Court vacated the district court’s order of mandamus and remanded the case again to the district court for further consideration. Specifically, the DC Circuit Court held that the district court did not

The Winding History of the Case This case has bounced back and forth from the district court to the court of appeals and back. Currently, it is at the district court, where HHS seeks to convince the court that the department cannot clear the backlog on any set timetable. Essentially, HHS asks the court to remove itself from the discussion and leave the backlog to HHS and Congress to solve.

The court held that hospitals have a clear right to ALJ decisions in 90 days; HHS has a clear duty to decide ALJ appeals in 90 days; and hospitals have no adequate alternative remedy other than mandamus.

Citing the FAIR Fund’s brief, the DC Circuit noted that the ALJ backlog is having a real impact on human health and welfare because some inpatient rehabilitation hospitals and units (IRH/Us) are admitting fewer cases that are likely to be targeted by auditors. The DC Circuit sent the case back (i.e., “remanded”) to the district court, however, to determine whether Congress and HHS are making “significant progress” toward solving the ALJ backlog.

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

The DC District Court determined that the factors in favor of a writ of mandamus outweighed the factors against. The court mentioned the real impact on health and human welfare from the ALJ delay. The court discussed the statistics presented by the FAIR Fund showing that IRH/Us have at least $135 million tied up in the backlog. Because IRH/U-generated data demonstrates that IRH/Us win as many as 80 percent of their appeals—87 percent when the value of the claims are used to calculate the percentages—it follows that

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

The Medicare statute requires that ALJs issue decisions in 90 days. HHS has failed to meet this deadline for several years.

Decisions issued during the first three quarters of 2017 took 1,060.3 days on average to decide, more than 2.5 years past the deadline. Currently, there is a backlog of more than 530,000 appeals at the HHS Office of Medicare Hearings and Appeals (OMHA). Therefore, the AHA has requested a “writ of mandamus,” which is court order requiring a government official to comply with a clear duty. Here, the duty is to decide ALJ appeals in 90 days.

There are typically two stages to a mandamus case. First, a plaintiff must show that the court has jurisdiction by establishing the following: 1) that the 8

ABOUT THE AUTHORS

AMRPA Magazine January 2018

adequately consider HHS’s argument that it is impossible to clear the backlog in four years. Thus, on remand, the district court must decide whether HHS can clear the deadline while also complying with its statutory obligation to pay meritorious claims. HHS’ motion for summary judgment urges the district court to find in its favor, while providing new information on the backlog and its efforts to clear the pending appeals.

OMHA and CMS Efforts to Reduce the Backlog The current appeal backlog sits at more than 530,000 appeals pending for ALJ hearings. Based on available funding, in fiscal year (FY) 2017, OMHA only had capacity to decide 76,000 appeals. In FY 2018, that capacity will rise to 93,500 appeals (representing 92 ALJ teams), but with OMHA receiving well in excess of 100,000 new hearing requests each year, even this increased capacity is not sufficient. At these levels of incoming appeals, OMHA is not able to keep up with the volume of requests on a year-toyear basis, much less reduce the backlog.

Furthermore, while HHS maintains that denials by Recovery Audit Contractors (RACs) represent only a small proportion

of these appeals, the department does not acknowledge that the RACs have been on a hiatus for several years and that newly-contracted RACs have only been operational for a short time. Even with significant limits placed upon the new RACs, their reemergence on the audit scene, along with the increased activity of the Supplemental Medical Review Contractor (SMRC), is bound to cause an increase in the number of denials and appeals.

In recognition of the inability of ALJs to clear the appeal backlog, OMHA has implemented a number of measures designed to handle large numbers of appeals in batches. First, since 2015, approximately 5,000 appeals have been resolved by OMHA senior attorneys under appellant requests for decisions on the written record without a hearing.

The number of appeals handled this way is likely to remain small however, since only the appellant may request an onthe-record decision. Many appellants are understandably hesitant to make the request and forego the right to provide testimony to the ALJ, which can be critical to winning and represents the most favorable forum for providers.

Another more successful hearing alternative has been the Settlement Conference Facilitation (SCF) program.

This program has resulted in the disposition of 15,500 appeals so far. As of Sept. 30, 2017, 202 providers have requested SCF, with 53 proceeding to settlement. However, 104 of the providers were not actually eligible to participate in SCF, but OMHA will be expanding the SCF program soon to make it available to more providers. Another 18 providers failed to reach a mutually agreed upon settlement, possibly due to the low reimbursement level offered by the Centers for Medicare and Medicaid Services (CMS).

OMHA has also proactively contacted an additional 18 providers to assess their interest in pursuing settlement under the SCF program. However, only four of these providers have proceeded to settlement, with three ultimately deemed ineligible to participate and eight not responding to the overture.

While the SCF program has experienced modest success, OMHA’s voluntary statistical sampling program has been far less successful. This program likely consumes enormous resources given the complexity of adjudicating a sample of 9

appeals in a fair manner. The SCF program has resolved only 532 appeals to date.

However, an additional 14,000 appeals are currently in the process of being resolved.

These settlements represent the appeals of only seven providers. OMHA estimates that an additional 459 providers would be eligible for the program.

In addition to OMHA’s efforts, CMS has taken steps to help alleviate the number of claim denials that make it to OMHA as requests for hearing. CMS settled with state Medicaid agencies from Connecticut, New York, and Massachusetts, removing approximately 54,000 appeals from the backlog and preventing the filing of an additional 9,000 appeals.

CMS recently established the nationwide Targeted Probe and Educate (TPE) Program, which allows providers to discuss claim errors with the Medicare Administrative Contractors (MACs), hopefully in an effort to reduce the number of errors, resulting denials, and appeals entering the OMHA system. CMS has established an accuracy review team to verify, on a monthly basis, that contractors are making accurate determinations and applying Medicare policies consistently. In addition, CMS uses validation contractors to ensure the accuracy of reviews carried out by the Recovery Audit Contractors (RACs). CMS also limits its appeal contractors (i.e., the MACs and the QICs) to the initial reason for a claim’s denial throughout the appeal process rather than permitting the use of additional or changing reasons to justify any denials.

CMS also launched a discussion period demonstration project for durable medical equipment (DME) suppliers in 37 states that allows the suppliers to have telephonic contact with the Qualified Independent Contractor (QIC) about their appeals in an attempt to resolve denied claims prior to reaching OMHA. Since DME suppliers represent a huge proportion of the appeals in the backlog, CMS anticipates a high reduction in pending appeals (approximately 103,000) as a result of this demonstration. (In fact, a single DME supplier represents approximately 31 percent of the appeals backlog. In contrast, the acute care hospital with the largest number of pending appeals is only the 31st largest appellant, accounting for only 10

0.19 percent of the total pending appeals.)

In another effort that largely impacts DME, CMS instituted prior authorization requirements for certain items and/or jurisdictions. The anticipated effect of this initiative is a reduction of 323,000 appeals that are likely to be prevented from entering the queue between now and the end of FY 2021.

claims from the ALJ backlog. If a provider has an alternative that allows for timely disposition of its appeals (such as a mass settlement) but chooses to maintain its appeals, at least the provider chose to continue its claims and had a meaningful alternative—a major difference from the outlook most appellants currently face in light of the backlog.

Settlement Options HHS touts its current efforts to clear the backlog and acknowledges that it is currently engaged in discussions with AMRPA and the FAIR Fund on behalf of IRH/Us to negotiate a potential settlement of pending inpatient rehabilitation appeals.

HHS estimates that such a settlement could remove up to 15,000 appeals from the backlog. Nonetheless, HHS rejects the possibility of using widespread settlements to handle the backlog.

Despite its seeming opposition to mass settlements, HHS recently announced an initiative to settle all eligible appeals for “low volume” appellants. Specifically, for appellants with fewer than 500 appeals pending at the ALJ level or before the Medicare Appeals Council, and for which each claim is worth $9,000 or less, HHS is offering payment of 62 percent of the claim value. This initiative will likely dispose of a great many DME-related appeals, but is unlikely to impact appeals based on claims for IRH/U services, which are typically worth more than $9,000 each. HHS’ estimates are for 80 percent of appellants to be impacted by low volume appeals (LVA) initiative, encompassing approximately 166,000 appeals.

HHS insists that an order to clear the backlog on a set timetable would force it to violate the statutory requirement to pay only meritorious claims. Further, HHS points to the discretion of appellants in choosing to accept (or not) any settlement offers made as a reason why it is not proper for the district court to order HHS to clear the ALJ backlog in four years. HHS posits that instituting mass settlements will incentivize appellants to file appeals indiscriminately and reduce their incentive to enter into any reasonable settlement, knowing that HHS is under duress to settle appeals by a certain time.

HHS also notes that some of the providers and suppliers with appeals pending in the backlog are the subject of program integrity investigations. HHS presents this as another reason why mass settlements would cause non-meritorious claims to be paid. HHS failed to acknowledge the department’s own power to limit such settlements to cover only appellants without such concerns hanging over them.

HHS points to the acute care hospital “short stay” settlement from 2014 (and its revival in 2016) as a source of disposition for a large number of claims. The drawback that HHS seeks to emphasize is that not all hospital appellants chose to accept the settlement. But this argument ignores the fact that the short stay settlement removed hundreds of thousands of

Conclusion No matter what the district court decides, another appeal to the DC Circuit seems certain. HHS argues that lawful compliance with any mandamus order is impossible.

This is because any attempt—it asserts— to mandate HHS to comply with targets to meet the 90-day statutory deadline for issuing ALJ decisions would be “extraordinarily unfair and inequitable,” requiring it to continually offer mass settlements to appellants whose claims are without merit and who may pose program integrity concerns. The provider community feels strongly that HHS has an obligation to comply with the statutory ALJ deadline so that providers can vindicate their coverage decisions and receive payment in a reasonable time. Thus, either side is likely to appeal the district court’s decision, which is likely to be issued in the spring or summer of 2018.

AMRPA Magazine January 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 Staff Associate, at sschwarz@amrpa.org or by calling 202-207-1132.

#AMRPA 11

2018: THE YEAR OF THE PPS COORDINATOR

By Lisa Werner, MBA, MS, CCC-SLP

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he Chinese Zodiac, an ancient astrological calendar still widely referenced in popular culture today, spans 12 years and assigns an animal to represent the significance of each of those years. I feel, out of respect for their position, that we should make 2017 the year of the PPS Coordinator.

PPS Coordinators have one of the most difficult jobs in the industry, and often receive little to no support simply because of the specificity of their duties.

However, everyone in a unit depends on them to not only consistently do their job well, but do it without ever expecting support from other members of the unit.

This isn’t for a lack of wanting to help, but because there are rarely other staff members who have the skills required for the job.

So, in recognition of the year of the PPS Coordinator, I would like to offer some suggestions for ways in which you and your staff can offer the PPS Coordinator support so that they can continue to support you and your teams as best they can.

1. Education: Ideally, mentorship begins immediately when a new coordinator is hired. The new employee works alongside the current PPS Coordinator and learns as much as they can before they are on their own. This acts as the de-facto training program for whenever this kind of staff change happens.

Additionally, eRehabData® offers a twoday, intensive workshop on coding the IRF-PAI. This class is most useful for those who already have a working knowledge of the IRF-PAI. In looking back at the previous outcomes of this workshop, 12

those who benefit the most have worked in this position for at least three months before attending the class. The class is meant to be introductory, but the unique terminology and verbiage used for the position requires at least some familiarity with the information to yield any positive outcomes. Without a basic understanding of rehab PPS and the rehab process, the new hire could easily be overwhelmed by the sheer quantity of the information they are required to learn. eRehabData® also offers monthly clinical training webinars for free, with many of the topics directed towards PPS coordinators. These are recorded and posted on the eRehabData® website for playback at any time. These recordings are useful for anyone who misses training sessions or anyone who wants to revisit the information given during the training.

We also offer proficiency exams for FIM scoring. These proficiency exams contain questions meant to not only test knowledge and skillsets, but also to educate. They work wonderfully as tools for educating PPS Coordinators who need to refresh their FIM knowledge or to study for training other rehab staff.

Our current version of the exam is under review so that quality indicator testing can be added to the present set of scenarios.

2. Networking: It is important to keep your PPS Coordinators connected with others working in the same position. Many states have rehab coalitions or associations, so it would be worthwhile to search for a listserv or other group/ groups that offer events in which PPS coordinators can participate. While

we continue to provide workshops in eRehabData®, and encourage subscribers to reach out to us whenever they have a question, sometimes it is easier to learn immediately useful skills and practices from peers and others in the field. Nothing can replace direct experience, especially if the coordinator has a question about a strange or never before encountered event. Continue to encourage and actively support networking as best you can.

3. Review key performance indicators: Keep a close eye on your eRehabData® facility reports, watch your key performance indicators for significant fluctuations, and drill down to determine what precipitated any changes you may find. Most importantly, closely monitor your rolling 90-day data in an effort to stay on top of incremental changes before too much time has passed. Assigning impairment groups, capturing burdens of care, and reporting comorbidities on the IRF-PAI is more art than it is science, and any changes in physicians and their documentation can have devastating impacts on your case mix index. Pay close attention to all of these moving parts and probe staff for explanations as soon as you notice any aberrations. Make sure that the PPS Coordinator is able to explain any notable changes.

4. Check the details of the 60% rule report: It is important to look beyond your 60% rule percentages to get a full picture of which patients are compliant, noncompliant, or excluded. Reviewing patient details is the best way to understand how your PPS Coordinator is designating compliance for patients who are not automatically counted. It is a stretch to expect the rehab manager AMRPA Magazine January 2018

to understand the finer details of those reports, but I do believe that they can easily spot any notable trends by spending around an hour a month reviewing the entire report. Respond to any notable trends the same way you would respond to fluctuations in case mix index or increases in discharges to acute care.

5. Cross train a back-up PPS coordinator: Because of the uniqueness and specificity of the PPS Coordinator’s job, it is worthwhile to have another staff member who understands enough about the position to provide support in any situation that may require it.

The staff member chosen to undertake this training should have a clinical background in order to make sense of the information in the records. When PPS coordinators complete the IRF-PAI, they check to make sure that the data they have is supported by the charts.

Having a clinical background gives the trainee a much greater chance of being able to provide worthwhile support and understand the nuances of the position.

Treat the PPS position as an investigative

position rather than one simply for data entry.

6. Stay on top of IRF-PAI completion and transmissions: The PPS Coordinator should finalize IRFPAI’s within a week of patient discharges.

The IRF-PAI must be transmitted to CMS before a bill can be dropped. You should encourage PPS Coordinators to have the document completed and sent within seven days of a discharge. There is a report in eRehabData® that will tell you when IRF-PAI’s are transmitted, so it is a good practice to always keep up with the timeframes in which transmissions are being made. Also, keep an eye on the Override Report, which will alert you when IRF-PAI’s are submitted with incomplete data. If more than 5 percent of your IRF-PAI’s are submitted with incomplete data, you will receive a 2 percent payment reduction across the board for Medicare payments in the next fiscal year.

7. Compare actual reimbursement to expected reimbursement: Make sure that you are being adequately reimbursed. For each patient in the

eRehabData® database, attached to their information is also an expected reimbursement.

This amount is calculated based on the Medicare PPS reimbursements for the year.

Reconcile those numbers with the actual reimbursement payments you receive to make sure that there are no discrepancies. The typical errors that cause discrepancies in payment are incorrect discharge destinations reported on the bill, short-stay default payments, and long-stay outlier patients.

Because PPS Coordinators hold the key to your facilities Medicare reimbursement, it is especially important that you have competent staff who are able to fulfill their positions with the utmost accuracy and efficiency. To help make sure that your PPS Coordinators are able to succeed in their positions, do the best that you can to educate, cultivate, and surround them with staff who are able to properly assist them in doing the best job that they can possibly do. Your Medicare reimbursement are almost entirely contingent on success at this position.

13

EPISODE PAYMENT MODELS AND CARDIAC REHABILITATION INCENTIVE PROGRAMS CANCELLED; COMPREHENSIVE JOINT REPAIR PROGRAM MODIFIED

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

O

n November 30, the Centers for Medicare & Medicaid Services (CMS) issued a final rule cancelling and rescinding the Episode Payment Models (EPMs), including the Surgical Hip/Femur Fracture Treatment (SHFFT), as well as the Cardiac Rehabilitation (CR) Incentive Payment Model. In addition, it extensively modified the Comprehensive Care for Joint Replacement (CJR) Model with the major change being to shift 33 metropolitan statistical areas (MSAs) to a voluntary status for the affected hospitals with the balance still requiring mandatory participation. The rule also includes an interim final rule with comment focused on the concerns and needs of those hospitals in the CJR MSAs affected by all of the recent natural disasters including hurricanes, floods and fires. All the changes were completely consistent with the proposed rule CMS issued on August 15, 2017. The effective date of all the changes is January 1, 2018.

AMRPA filed an extensive comment letter on the proposed rule, supporting many of the changes proposed by CMS. AMRPA had taken the position earlier, when many of the models were developed, that they were premature, chaotic, burdensome, lacking in recognition of rehabilitation hospitals and units, as well as lacking in appropriate quality metrics, among other issues. This recent move by CMS acknowledges many of these concerns, which were expressed by multiple stakeholders.

AMRPA did, however, 14

recommend to CMS that it consider implementing a cardiac rehabilitation incentive program relatively soon, as the clinical benefits of such programs are heavily documented in support of excellent outcomes. CMS did state that as it develops the Innovation Center’s portfolio of models, it may revisit the concept of a CR focused model and will consider stakeholder feedback.

CMS continues to believe that cardiac and orthopedic episode models offer opportunities to redesign care delivery and improve quality and care coordination while lowering spending. However, it determined that it was necessary to rescind the regulations. As stated in the proposed rule, it believes that requiring hospitals to participate in additional EPMs at this time is not in the best interest of the agency or the affected providers.

Many providers are currently engaged in voluntary CMS initiatives such as the Bundled Payments for Care Improvement (BPCI) Initiative and Accountable Care Organizations (ACOs), and CMS expects to continue offering initiatives, including episode-based payment models. It also believes that reducing the number of providers required to participate in the CJR model would allow it to continue to evaluate its effects while limiting the geographic reach of the current mandatory models. As stated in the proposed rule, CMS considered altering the design of the EPMs and the CR to allow for voluntary participation and to take into account other feedback on the models. However, this change would have

Highlights: •

•

CMS pulls back from mandatory bundling as anticipated for EPMs, cardiac rehab and modifies CJR. New voluntary bundling programs may be on the horizon.

potentially involved restructuring the model design, payment methodologies, financial arrangement provisions and/ or quality measures, and CMS did not believe that such changes would offer providers enough time to prepare, given the planned January 1, 2018, start date.

In addition, if at a later date it tests these or similar models, it would announce them via the Innovation Center and not rulemaking.

CMS stated previously that if the proposal to cancel the EPMs and CR was finalized, providers interested in participating in bundled payment models would have an opportunity during calendar year (CY) 2018 via new bundled payment models.

The Innovation Center expects to develop new bundled payment model(s) during CY 2018 that would be designed to meet the criteria to be an Advanced Alternative Payment Model (APM). One of these models is expected to be another BPCI program or expansion. It also noted the strong evidence base and other positive stakeholder feedback regarding the CR Incentive Payment Model.

AMRPA Magazine January 2018

CMS noted further that it had recently requested comment on the new direction it is establishing for the Innovation Center, which included promoting patient-centered care and testing market driven reforms to empower beneficiaries, provide price transparency, increase choices and competition to “drive quality, reduce costs and improve outcomes.”

Addressing its new directions, the agency said that “new models will be designed to reduce burdensome requirements and unnecessary regulations to the extent possible to allow physicians and other providers to focus on providing high quality healthcare to their patients.”

Modification to the CJR Program •

Participation Election (Opt In) for Certain MSAs and Low-Volume and Rural Hospitals in the CJR Model The CJR Model will continue on a mandatory basis in 34 of the 67 MSAs, with an exception for lowvolume and rural hospitals, and will continue on a voluntary basis in the other 33 MSAs. CMS is excluding low-volume hospitals (those having fewer than 20 CJR episodes in total across the three historical years of data) from required participation in the CJR Model beginning February 1, 2018, regardless of their geographic location. However, low-volume hospitals can choose to voluntarily participate and must make a onetime participation election that complies with the CJR regulations or be automatically dropped from the CJR Model. CMS also excludes rural hospitals with a CMS Certification Number (CCN) primary address in the 34 mandatory participation MSAs from required participation in the CJR Model beginning February 1, 2018. Similarly, rural CJR hospitals that choose to voluntarily continue in the model must also make a one-time participation election or it will be automatically dropped from continued participation. Hospitals eligible for voluntary participation who do not elect to participate will have all their performance year 3 episodes (i.e., those episodes ending on or after January 1, 2018, and before January 1, 2019) cancelled. A summary of the changes to the CJR Model participation requirements are

shown in the table on page 16.

•

•

Clinician Engagement Lists To increase opportunities for eligible clinicians supporting CJR Model participant hospitals by performing CJR Model activities and who are affiliated with participant hospitals to be considered Qualifying APM Participants (QPs), CMS finalized the proposal that participant hospitals that choose to participate in the Advanced APM track would submit a clinical engagement list with information for each physician, nonphysician practitioner or therapist who is not a CJR collaborator during the period of the CJR Model performance year specified by CMS, but who does have a contractual relationship with the participant hospital based at least in part on supporting the participant hospital’s quality or cost goals under the CJR Model during the period of the performance year specified by CMS. The clinician engagement list will also be considered an Affiliated Practitioner List. The clinician engagement list and the clinician financial arrangement list are considered together as an Affiliated Practitioner List and will be used by CMS to identify eligible clinicians for a QP determination based on services furnished through the Advanced APM track of the CJR Model. AMRPA has supported the creation and expansion of these lists.

Codification of CJR Model-related Evaluation Participation This final rule adds provisions to the regulations to specify that CMS may take remedial action if a participant hospital, or its collaborators, collaboration agents and downstream collaboration agents, fails to participate in model related evaluation activities conducted by CMS and/or its contractors.

•

Clarification of CJR Reconciliation Following Hospital Reorganization Events Reorganization events that involve a CJR Model participant hospital and a hospital that is not participating in the CJR Model and result in the new organization operating under the CJR participant hospital’s CCN do not affect the reconciliation for the CJR participant hospital for episodes that initiate before the effective date of the reorganization event. Episodes that initiate after a reorganization event will be subject to an updated quality-adjusted episode target price that is based on historical episodes for the CJR participant hospital, which will include historical episode expenditures for all hospitals that are integrated under a given CCN. These policies have been in effect since the start of the CJR Model on April 1, 2016. However, to further clarify this policy for the CJR Model, CMS added a provision specifying that separate reconciliation 15

calculations are performed for episodes that occur before and after a reorganization that results in a hospital with a new CCN. CMS believes this clarification increases transparency and understanding of the payment reconciliation processes for the CJR Model.

•

MSA name

Wage-adjusted episode payments (in $)

10420

Akron, OH

$28,081

11700

Asheville, NC

27,617

Austin-Round Rock, TX

28,960

13140

Beaumont-Port Arthur, TX

32,544

17140

Cincinnati, OH-KY-IN

28,074

18580

Corpus Christi, TX

30,700

20020

Dothan, AL

30,710

22500

Florence, SC

27,901

23540

Gainesville, FL

29,370

24780

Greenville, NC

27,446

25420

Harrisburg-Carlisle, PA

28,360

26300

Hot Springs, AR

29,621

28660

Killeen-Temple, TX

27,355

31080

Los Angeles-Long Beach-Anaheim, CA

28,219

Clarification of Use of Amended Composite Quality Score Methodology During CJR Model Performance Year 1 Subsequent Reconciliation

31180

Lubbock, TX

29,524

32820

Memphis, TN-MS-AR

28,916

33100

Miami-Fort Lauderdale-West Palm Beach, FL

33,072

33740

Monroe, LA

30,431

CMS conducted the initial reconciliation for performance year 1 of the CJR Model in early 2017, and has made initial reconciliation payments to CJR participant hospitals accordingly. Preliminary year 1 reconciliation results are available on the CMS website at https://innovation.cms.gov/initiatives/ cjr. CMS will conduct the subsequent reconciliation calculation for CJR performance year 1 beginning in the first quarter of 2018, which may result in additional amounts to be paid to participant hospitals or a reduction to the amount that was paid for performance year 1. However, the results of the performance year 1 subsequent reconciliation calculations will be combined with the performance year 2 initial reconciliation results before further payments are processed for disbursement or collection.

33860

Montgomery, AL

30,817

Adjustment to the Pricing Calculation for the CJR Telehealth HCPCS Codes to Include the Facility Practice Expense (PE) Values

In a final rule issued on January 3, 2017, regarding EPMs and the CJR model, CMS revised the methodology used to determine the quality-adjusted target price.

Specifically, the methodology used to determine the quality-adjusted target price for the performance year 1 subsequent reconciliation 16

MSA

12420

This final rule replaces the zero PE value currently used in the CJR Telehealth HCPCS Code pricing calculation with use of the facility PE relative value units (RVUs) for the analogous services in pricing the 9 CJR HCPCS G-codes. AMRPA supported this proposal.

•

Table 1. CJR Mandatory Participation MSAs

35300

New Haven-Milford, CT

27,529

35380

New Orleans-Metairie, LA

29,562

35620

New York-Newark-Jersey City, NY-NJ-PA

31,076

36420

Oklahoma City, OK

27,267

36740

Orlando-Kissimmee-Sanford, FL

29,259

37860

Pensacola-Ferry Pass-Brent, FL

29,485

38300

Pittsburgh, PA

30,886

38940

Port St. Lucie, FL

30,423

39340

Provo-Orem, UT

28,852

39740

Reading, PA

28,679

42680

Sebastian-Vero Beach, FL

28,015

45300

Tampa-St. Petersburg-Clearwater, FL

32,424

45780

Toledo, OH

28,658

46220

Tuscaloosa, AL

31,789

46340

Tyler, TX

30,955

calculation will differ from the methodology used to determine the quality-adjusted target price for the performance year 1 initial reconciliation calculation, which may result in significant differences between the reconciliation payments calculated during the performance year 1 initial reconciliation and the performance year 1 subsequent reconciliation. To remedy this

issue, CMS will apply the quality specifications as established in the final rule – that is, the amendments to §510.305 and §510.315 that became effective May 20, 2017 – to performance year 1 subsequent reconciliation calculations to ensure that reconciliation calculations for subsequent performance years will be calculated using the same methodology and to improve AMRPA Magazine January 2018

Table 2. CJR Voluntary Participation MSAs MSA

MSA name

Wage-adjusted episode payments (in $)

10740

Albuquerque, NM

$25,892

12020

Athens-Clarke County, GA

25,394

13900

Bismarck, ND

22,479

14500

Boulder, CO

24,115

15380

Buffalo-Cheektowaga-Niagara Falls, NY

26,037

16020

Cape Girardeau, MO-IL

24,564

16180

Carson City, NV

26,128

16740

Charlotte-Concord-Gastonia, NC-SC

26,736

17860

Columbia, MO

25,558

19500

Decatur, IL

24,846

19740

Denver-Aurora-Lakewood, CO

26,119

20500

Durham-Chapel Hill, NC

25,151

22420

Flint, MI

24,807

23580

Gainesville, GA

23,009

26900

Indianapolis-Carmel-Anderson, IN

25,841

28140

Kansas City, MO-KS

27,261

30700

Lincoln, NE

27,173

31540

Madison, WI

24,442

33340

Milwaukee-Waukesha-West Allis, WI

25,698

33700

Modesto, CA

24,819

34940

Naples-Immokalee-Marco Island, FL

27,120

34980

Nashville-Davidson—Murfreesboro—Franklin, TN

26,880

35980

Norwich-New London, CT

25,780

36260

Ogden-Clearfield, UT

25,472

38900

Portland-Vancouver-Hillsboro, OR-WA

22,604

40980

Saginaw, MI

25,488

41180

St. Louis, MO-IL

26,425

41860

San Francisco-Oakland-Hayward, CA

23,716

42660

Seattle-Tacoma-Bellevue, WA

23,669

43780

South Bend-Mishawaka, IN-MI

23,143

44420

Staunton-Waynesboro, VA

25,539

45820

Topeka, KS

24,273

48620

Wichita, KS

25,945

consistency across performance years for quality improvement measurement. Thus, for the reasons noted previously, CMS is not changing the amendments to §510.305 and §510.315 that became effective May 20, 2017.

•

Interim Final Rule Regarding Significant Hardship Due to Extreme and Uncontrollable Circumstances in the CJR Model

a county, parish, U.S. territory or tribal government designated as a major disaster area under the Stafford Act. For performance years 2 through 5, the following policies will apply to all CJR Model episodes for participant hospitals that are located in a designated emergency area: For non-fracture episodes with a date of admission to the anchor hospitalization on or within 30 days before the date that the emergency period begins, actual episode payments are capped at the target price determined for those episodes. For fracture episodes with a date of admission to the anchor hospitalization on or within 30 days before or after the date that the emergency period begins, actual episode payments are capped at the target price determined under §510.300.

•

Incentivizing Participation in CJR Model CMS sought comments on how to further incentivize providers to participate in the CJR model.

In its comment letter, AMRPA recommended broadening CJR to allow IRFs to initiate episodes and bear direct financial risk, and offer waivers of certain IRF payment policies to allow for additional flexibilities for post-acute providers.

CMS said that it will continue to consider these options “as we move forward with CJR and other models.”

This rule was published in the Federal Register on December 1, 2017.

The rule also includes an interim final rule with comment period to address the need for some flexibility in determining episode costs for CJR hospitals located in areas hit by extreme and uncontrollable circumstances. Specifically, this policy will apply to CJR hospitals located in areas for which the Secretary of HHS has issued a waiver if those CJR hospitals are also located in 17

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AMRPA Magazine January 2018

MEDPAC TO VOTE ON 5 PERCENT PAYMENT CUT FOR IRFS IN FY 2019

By Mimi Zhang, Policy and Research Associate, AMRPA

O

n Dec. 7-8, 2017, the Medicare Payment Advisory Commission (MedPAC) met to discuss recommendations regarding the fiscal year (FY) 2019 payment updates for Medicarecertified providers. This article covers the draft recommendations specific to inpatient rehabilitation hospitals and units (IRFs) and the recommendation to redistribute post-acute care (PAC) payments within each setting using a weighting system derived from MedPAC’s unified PAC prospective payment system (PAC PPS). This article covers, in total, MedPAC’s draft recommendations impacting the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) for FY 2019.

Specific to the IRF PPS, MedPAC’s draft recommendation essentially mirrors that made last year, and reads: For fiscal year 2019, the Congress should reduce the Medicare payment rate for IRFs by 5 percent. It seems that the Commission will also reiterate its past recommendations to expand the IRF PPS high-cost outlier pool and conduct targeted medical reviews to study the interrater reliability of IRF patient assessments.

The Commission also discussed the following draft recommendation to be applicable to all PAC settings: The Congress should direct the Secretary to begin to base Medicare payments to PAC providers on a blend of the settingspecific relative weights and unified PAC prospective payment system relative weights in FY 2019. Commissioners voiced support for both recommendations and will formalize them in January 2018 in an

expedited review and vote.

Highlights: MedPAC staff acknowledged that the 5 percent IRF payment cut may increase financial pressure on some providers, but believe that the effect should be eased by an accompanying expansion in the outlier pool and implementation of the PAC PPS-blended payment weights. Hence taken together, the IRF recommendations would have the combined effect of: •

Reducing total payments by 5 percent; but

•

The blended weights and expanded outlier pool would mitigate the effects on providers who care for more stroke cases and medically complex cases.

Finally, MedPAC projects the 2018 aggregate overall Medicare margin for IRFs to be 11.9, down from 13.0 percent observed in 2016.

Redistributing Payments with PAC PPS-Reblended Weights MedPAC staff reviewed the PAC PPSreblended weights policy, which was first brought forward to Commissioners in November. Notably, staff did not provide more information this month on the policy’s technical details, such as the patient characteristics used as factors or the weighting methodology. The policy approach will be addressed as a separate chapter in MedPAC’s March 2018 Report to Congress to precede the various PAC chapters. It remains to be seen if the chapter’s narrative will address any technical details.

•

At the December meeting, Commissioners supported a 5 percent IRF payment cut and within-silo PAC payment redistributions for FY 2019.

To summarize, the payment adjustment would occur within each PAC setting and blend current setting-specific patient case-mix adjusters with the patient casemix relative weights from MedPAC’s unified PAC PPS. MedPAC has been developing the unified PPS since 2015 with its contractor, the Urban Institute.

Recommended to begin in FY 2019, the policy would transition PAC settings from their current siloed fee-for-service PPSs to the unified PAC PPS under which payment is setting-agnostic and based instead on patient characteristics. Within each setting, the margin gap among provider types would effectively narrow, and payments would shift as follows: •

Increase for medically complex care and decrease for the furnishing of therapy unrelated to care needs;

•

Increase for nonprofit and hospitalbased providers; and

•

Decrease for for-profit and freestanding providers.

MedPAC believes this approach would increase the equity of payments within each setting before implementing a unified PAC PPS. According to the staff, the recommendation’s implications 19

include more equitable access for beneficiaries and especially for medically complex beneficiaries. Providers will have less incentive to selectively admit beneficiaries. The impact on individual providers, however, will vary based on their mix of cases and current practice patterns.

MedPAC staff also acknowledged that although this may be feasible from their analytical outlook, CMS has not agreed that it is feasible in the FY 2019 rulemaking cycle from an administrative perspective. CMS has also indicated they would need to develop independently a PAC PPS-reblended relative weighting system rather than use MedPAC’s work as a turnkey solution.

With support from all the Commissioners, the draft recommendation to will undergo expedited vote in January.

IRF PPS Discussion State of the Field In 2016, IRFs accounted for $7.7 billion of Medicare spending ($0.3 billion increase over 2015) with close to 1,200 providers and 391,000 cases. The average payment in 2016 was $19,700 per case (up from $19,100 in 2015) and Medicare beneficiaries comprised 60 percent of all discharges. IRFs’ Medicare fee-for-service volume has remained steady since 2007 and the number of cases per beneficiary increased slightly in 2016 by 1.4 percent.

The average occupancy rate was 65 percent.

for MedPAC by a contractor. These measures are: •

Gain in motor function: 24.4 points gained per stay on average in 2016

•

Gain in cognitive function: 4.0 points gained

•

Rate of discharge to community: 76.9 percent

•

Rate of discharge to SNFs: 6.7 percent

•

Potentially-avoidable hospitalization during IRF stay: 2.5 percent

•

Potentially-avoidable hospitalization within 30 days after discharge from IRF: 4.4 percent

Medicare Margins For 2018, MedPAC projects IRFs’ aggregate overall Medicare margin will be 11.9 percent. In 2016, the actual aggregate overall Medicare margins was 13.0 percent. Note that MedPAC had projected 2016 margins to be 13.5 percent. The margins by IRF type are as follows (all figures account for sequestration):

Some case types may be more profitable than others, and this is a factor in high-margin IRFs having a different case mix than lower-margin providers. Note that this is a change in tone from how the Commission has characterized this issue a year ago, which was simply “High-margin IRFs have a different mix of cases.” o To address this, staff reported that they will conduct a closer assessment of cost variations within the IRF case mix groups and profitability across the groups in the future.

•

Patient assessments may not be uniform across IRFs.

For the second year in a row, MedPAC staff focused on their prior analysis on profitability, case mix, and patients’ functional status assessments.

Referencing the table below, the staff specified that there is approximately a $4,000 difference in payment for withoutparalysis stroke patient at a lowestmargin IRF versus the highest-margin IRF,

IRF Medicare Margins, 2016 Percent of IRFs

Percent of Cases

Margin

Margin Change from 2015

All IRFs

100 percent

100 percent

13.0 percent

-0.8 percent

Freestanding

23 percent

50 percent

25.5 percent

-1.2 percent

Units

77 percent

50 percent

1.2 percent

-0.8 percent

Nonprofit

57 percent

41 percent

2.0 percent

-1.6 percent

For-profit

31 percent

52 percent

23.9 percent

-1.1 percent

IRF Marginal Profit, 2016 (profit of admitting one additional patient)

Between 2013 and 2016, the number of freestanding IRFs increased by 4.0 percent, the number of for-profit providers increased 4.7 percent, and the number of nonprofit providers held steady. Access to capital in the sector also remains adequate. As in past years, the staff reported that one major chain represents nearly half percent of all IRFs and experienced good market standing, while little information is available for others. Staff also noted that large IRF companies are pursuing vertical integration strategies and expanding service lines across the PAC continuum.

MedPAC attributes the decline in 2016 IRF margins to two factors: lower payment updates in recent years (1.9 percent update in FY 2017 pursuant to the ACA, and 1 percent in FY 2018 pursuant to the Medicare and CHIP Reauthorization Act of 2015 [MACRA]), and what appears to be higher cost growth than the market basket update, a deviation from preceding years’ trends.

Quality Since 2011, IRF quality performance has remained stable or improved according to six risk-adjusted measures developed

Ongoing Concerns with the IRF PPS MedPAC staff summarized the Commission’s ongoing concerns with the IRF PPS as follows:

20

•

Marginal Profit

Change from 2015

Freestanding

40.9 percent

-0.6 percent

Units

19.3 percent

-1.2 percent and a two-day difference in lengths of stay between an IRF patient with paralysis versus one without paralysis.

The staff then addressed the factors they believe contribute to higher costs in IRF units: •

The majority of units are nonprofit and may be less focused on cost control. o From 2009-2016, costs in nonprofit IRFs grew 17.9 percent versus 7.4 percent for freestanding IRFs. AMRPA Magazine January 2018

•

Units tend to be smaller with lower occupancy and fewer economies of scale.

Average IRF Motor Score at Admission by Type of Stroke, for IRFs with the Lowest and Highest Margins (2013) Motor score

o 66 percent of units have fewer than 25 beds.

• •

Type of Stroke

Units tend to have a different mix of patients Units may assess their patients differently.

The Commissioners supported the draft recommendation to reduce IRF payments by 5 percent in FY 2019, and to reiterate its prior

Lowest Margin IRFs

Highest Margin IRFs

With paralysis

29.2

24.6

Without paralysis

35.3

29.0

recommendations for the Secretary to expand the high-cost outlier pool and assess interrater reliability of IRF assessments. MedPAC will vote on the final IRF recommendations in an expedited review on Jan. 11-12, 2018.

Presentation slides and a meeting transcript are available at http:// medpac.gov/-public-meetings.

Stroke

“Other Neurological”

IRF units

24 percent

10 percent

Freestanding IRFs

17 percent

18 percent

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

Date

Note

House

Senate

January 15 January 22 − 26

Martin Luther King Jr.

X

X

-

X

February 19 − 23

Presidents’ Day

X

X

March 26 − April 6

Spring Holiday

X

X

April 30 − May 4

-

X

X

May 28 − Jun 1

Memorial Day

X

X

July 2 − 6

Independence Day

X

X

July 30 − August 3

Summer

X

August 6 − 31

Summer

X

X

September 3

Labor Day

X

X

September 17 − 21

Yom Kippur

X

October 8

Columbus Day

X

October 15 − November 9

-

X

October 29 − November 12

-

November 19 − 23

Thanksgiving Break

X

X

December 17 − 28

Winter Holiday

X

X

X X

X = State/District Working Period

21

BPCI YEAR 3 EVALUATION RESULTS SHOW SAVINGS FOR JOINT REPLACEMENTS BUT MIXED (TO DISAPPOINTING) QUALITY SIGNALS

By Mimi Zhang, Policy and Research Associate, AMRPA

I

n October 2017, the Centers for Medicare and Medicaid Services (CMS) recently released its third annual report on the Bundled Payment Care Improvement (BPCI) Initiative. In this evaluation report (the third of five), based on the first two years of the program, providers’ behavioral changes in response to bundled payment incentives are coming into light. Yet the authors of the report (the Lewin Group under contract with CMS) caution that “the effects are far from clear or straightforward” and emphasize the short tenure of the typical BPCI participant and the relatively limited data to date.

Nonetheless, one of the strongest patterns seen across all models and episodes is less intensive use of post-acute care (PAC), especially as it relates to major joint replacement bundles. However, a closer look at the quality outcomes under BPCI particularly for some episodes initiated in skilled nursing facilities (SNFs), and possible patient selection issues give cause for concern as the program continues.

Background Launched under the authority of the CMS Innovation Center in 2013, the BPCI initiative is designed to test whether bundling payments for Medicare-covered items and services during an episode of care related to an inpatient hospitalization can reduce Medicare expenditures, and whether those savings can be achieved while maintaining or improving quality of care. As a voluntary program, BPCI Awardees or Episode Initiators (also collectively referred to as “participants” for the purposes of this article) agreed to be financially accountable to CMS for the total cost of their chosen episode(s). Participants determine the key characteristics of their specific bundles, choosing among four payment Models, 48 clinical episodes, three episode lengths (30, 60, or 90-day) three risk tracks, and various waivers of Medicare rules 22

or fraud and abuse law.

Highlights: The four BPCI payment models differ in the services included in the episode design, payment method and eligible participants summarized in the table below. As in past years, the report evaluates the progress of Models 2, 3 and 4 to date; Model 1 is evaluated separately. This article focuses on the key results from BPCI Models 2 and 3 over the period of October 2013 to September 2015.

•

•

•

Models 2 and 3: Key Participant Characteristics Awardees in Models 2 and 3 are financially

Bundled payments for major joint replacements show promise for lowering episodic spending.

Preliminary results continue to show mixed quality outcomes, particularly for Model 3 episodes.

Very low uptake on regulatory waivers for SNF three-day hospital stay, telehealth and home visits.

Model 1

Model 2

Model 3

Model 4

Episode

All DRGs; all acute patients

Selected DRGs; hospital plus post-acute period

Selected DRGs; postacute period only

Selected DRGs; hospital plus readmissions

Services included in the bundle

All Part A services paid as part of the MS-DRG payment

All nonhospice Part A and B services during the initial inpatient stay, post-acute period and readmissions

All nonhospice Part A and B services during the post-acute period and readmissions

All non-hospice Part A and B services (including the hospital and physician) during initial inpatient stay and readmissions

Payment

Retrospective

Retrospective

Retrospective

Prospective

Eligible Episode Initiators (EIs)

Acute care hospitals

Acute care hospitals, physician group practices (PGPs)

PGPs and PAC providers: SNF, inpatient rehabilitation hospitals and units (IRF), long-term care hospitals (LTCH), home health agencies (HHA)

Acute care hospitals The majority of Model 4 hospitals (61%) have withdrawn during the first two years of BPCI.

AMRPA Magazine January 2018

Providers that chose to participate in BPCI are generally larger, urban and in more affluent areas. While Model 3 had the most Episode Initiators (EIs) by number of participating providers, the vast majority of episodes across all Models (85 percent) were initiated under Model 2.

o HHA payments increased in 19 of the 23 Model 2 clinical groups. Notably, those groups with the highest baseline PAC use increased their HHA use and reduced SNFs use in BPCI. As noted before, only MRJLE episodes had statistically significant differences in overall PAC spend.

to institutional PAC by 10.2 percentage points (62.5 percent to 52.3 percent), while the comparison group reduced the share of patients discharged to institutional PAC from 4.3 percentage points (61.2 percent to 56.9 percent) over the same period.

rewarded for reducing episodic Medicare payments relative to a target price that is determined by CMS based on the historical payments. Participants are incentivized to reduce aggregate episode payments. When aggregate Medicare episode payments are less than the target price, participants may receive net payment reconciliation amounts (NPRA) that reflect the difference, which they can keep or share with their partnering providers in gainsharing arrangements. When aggregate episode payments are higher than the target price, they may have to pay CMS.

o Relative to the comparison group, SNF payments were $711 lower and IRF payments were $435 lower under Model 2.

o Lewin states that the interviewed participants reported reducing their PAC use by changing patient and physician expectations about the need for PAC through education and consistent messaging by hospital staff.

o For Model 2 beneficiaries who had any SNF use, the average number of days decreased 1.5 days relative to the comparison group. •

BPCI participants shifted PAC use from IRFs and SNFs to HHAs: o The proportion of patients discharged to institutional PAC declined by nearly two-thirds (61 percent) in all Model 2 clinical episodes.

- Specifically, this drop was statically significant in 3 clinical groups: MJRLE, Cardiac valve and Other respiratory conditions.

Model 3 Results Only two of the 14 Model 3 clinical episodes, SNF MJRLE and HHA CHF, achieved statistically significant reductions in Medicare payments. Again, these savings were achieved through reduced PAC utilizations, with providers adjusting factors within their control, i.e., reducing SNF lengths of stay and HHA episodes. Lewin notes that the lack of payment effects could be due to the short

BPCI Clinical Groups with the Most Participation by EIs Model 2 1. Major joint replacement of lower extremity (MJRLE)

BPCI Impacts on Payment Across Models 2-4 and across all clinical groups, major joint replacement of the lower extremity (MRJLE) episodes produced the most statistically significant savings, relative to a non-BPCI comparison cohort. BPCI participants achieved their savings primarily through reducing PAC utilization which has been a consistent theme since the beginning of the initiative.

Model 2 Results •

Payments for Model 2 MJLRE episodes were 4.5 percent ($1,273) lower than the comparison group. o Model 2 hospital EIs reduced their share of MJRLE patients discharged

60% of EIs are participating in MJRLE bundles

2. Congestive heart failure

27%

3. COPD

27%

4. Simple pneumonia and respiratory infections (SPRI)

25%

5. Sepsis

24%

6. Hip and femur procedures except lower joint

21%

7. Acute myocardial infarction (AMI)

19%

8. Urinary tract infection

18%

9. Medical non-infectious orthopedic

18%

10. Cellulitis

16% Model 3

1. Major joint replacement of lower extremity (MJRLE)

32%

2. Simple pneumonia and respiratory infections (SPRI)

25%

3. Congestive heart failure

23%

4. COPD

22%

5. Urinary tract infection

18%

6. Other respiratory

18%

7. Sepsis

17%

8. Stroke

17%

9. Acute myocardial infarction

17%

10. Hip and femur procedures except lower joint

16% 23

timeframe of BPCI participation since the results reflect an average of three quarters in BPCI. Key results include: •

•

•

Payments for Model 3 MJLRE episodes for SNF EIs were 7.1 percent lower than the facilities’ baseline historic payments.

Relative to a comparison group, SNF payments for BPCI MJLRE episode were $2,255 lower.

The average number of days in a SNF declined in nine of 11 clinical groups, although only two groups were statistically significant.

•

For eight ADL measures, there was a statistically significant relative increase in the proportion of BPCI patients who improved over their PAC stay.

Lewin also assessed changes in three ADL Improvement measures for patients who stayed in the SNF or HHA long enough for both admission and discharge assessments. The ADL Improvement measures were: Improved self-care function, Improved mobility function, and Improved overall function.

•

Payments for HHA CHF episodes were 3.6 percent lower than baseline payments.

BPCI Impacts on Quality and Patient Experience of Care

•

Model 2 Results During the first 2 years of the BPCI initiative, Lewin found few statistically significant differences in quality of care across Model 2 episodes. Of 63 claims-based quality outcome measures, four indicators improved under the BPCI Model 2 and six declined (though only two of those were statistically significant):

staff clearly explained what follow-up care is needed prior to discharge (-2.8 percent). They were, however, more likely to report that they never received conflicting advice from the medical staff (+6.5 percent).

stay.

Two clinical episode groups in Model 2 (nutritional and metabolic disorders, and cardiac valve) showed relative improvements in at least 1 ADL measure.

•

Pneumonia: BPCI respondents were less likely to agree that their preferences for post-discharges services were considered (-4.6 percent), and less likely to agree that they understood how to take care of themselves after discharge (-4.2 percent)

•

Sepsis: BPCI patients with sepsis reported several worse changes in functional status and were also significantly more likely to report symptoms of depression. These respondents also reported worse experiences on four heath care experience measures including: receiving conflicting advice from medical staff (-8.0 percent), having always received the appropriate level of care (-8.4 percent), medical staff always speaking to them in their preferred language (-4.1 percent), and patient preferences being taken into account in deciding post-discharge care (-3.8 percent).

However, five clinical episodes demonstrated at least one statistically significant relative decline: MJRLE, revision of the hip or knee, sepsis, noncervical spinal fusion, and stroke.

Model 2 BPCI beneficiaries reported better functional outcomes for some clinical episodes, but significantly worse care experiences than their non-BPCI counterparts.

In addition to claims-based and assessmentbased quality measures, Lewin also assessed indicators of patient-reported changes in functional status and patient experience of

Model 3 Results Measure

Change Due to BPCI (percentage points)

Mortality: Renal failure

-2.4: Improvement

Morality: Nutritional and metabolic disorders

-3.6: Improvement

Mortality: AMI

-2.5: Improvement

ED use: Stroke

-2.3: Improvement

Unplanned readmissions: Hip and femur procedures except major joint

+2.7: Decline

ED use: Spinal fusion

+4.5: Decline

Assessment-based measures for PAC users under Model 2 did not indicate systematic quality issues relative to non-BPCI beneficiaries. Lewin examined changes across 211 activities of daily living (ADL) for patients discharged to SNF, IRF, or HHA care. They found: •

•

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No patterns in the change in ADLs between the Model 2 BPCI and comparison patients across 211 ADL measures in the three PAC settings.

For 14 of the ADL measures, there was a statistically significant relative decline in the proportion of BPCI patients who improved over the course of their PAC

care, finding that: •

•

Quality of care outcomes under Model 3 show the mixed and inconclusive impacts of BPCI. Across results for Model 3 SNF episodes, Lewin found “concerning declines” in claims-based quality indicators such as 90day readmissions, mortality and emergency department (ED) use, while remarking that these claim-based quality outcomes are based on a small number of EIs and patients.

Declines in claims-based indicators were accompanied by improvements in several assessment-based ADL measures, indicating

BPCI beneficiaries with MLJRE or cardiac arrhythmia reported better changes in functional status Measure relative to the comparison group.

Readmission: MJRLE MJRLE: On patient experience measures, BPCI respondents were less likely to report that they were discharged at the right time (-3.4 percent difference relative to the comparison group), and less likely to agree that medical

Change Due to BPCI (percentage points) -2.5: Improvement

Mortality: MJRLE

-1.3: Improvement

Readmissions: Renal failure

+6.3: Decline

Readmission: Stroke

+6.1: Decline

ED use: Sepsis

+3.5: Decline

Mortality: COPD

+7.3: Decline

Mortality: Renal failure

+5.1: Decline

Mortality: SPRI

+3.8: Decline AMRPA Magazine January 2018

patient selection can occur for surgical episodes because a SNF could more effectively identify a surgical patient based on MS-DRGs, versus medical MSDRG, as a BPCI episode.

that BPCI is associated with an improvement in ADLs for these subsets of patients. The statistically significant ADL results for Model 3 SNFs are: Clinical Episodes

ADL Changes Due to BPCI

CHF clinical episodes

Improvement in all three measured ADLs

Other respiratory, Renal failure, SPRI, Medical non-infectious orthopedic, and Urinary tract infection

Improvement in at least two of three ADLs

MJRLE

Decline in one ADL measure (A 9.2 percentage point decline in episodes with improved selfcare function)

For Model 3 HHA episodes, BPCI did not appear to have a systematic effect, either positive or negative, on the quality of care.

Further Observations Unintended consequences: Patient complexity appeared to change once providers began participating in BPCI, raising concern for selection issues. There are trends suggesting that BPCI participants may be selecting healthier, and therefore less costly, patients when compared with historic admissions data. This would be an important issue under BPCI because changes in the target payment amount is based on historical episode spending and it is not adjusted for changes in patient mix. However, the evidence about potential patient selection, as listed below, was not consistent across episode groups: •

•

In Model 2, there was a statistically significant decline in prior health services use for MJLRE non-fracture episodes, which are planned and elective care episodes.

In Model 3, BPCI SNFs had a less severe mix of fracture and non-fracture MJRLE patients compared to their baseline pre-BPCI timeframe, based on patients’ functional status upon admission.

According to Lewin, it is notable that this is the case for a surgical episode, because it is more likely that PAC

•

Model 3 BPCI-participating HHAs’ had significantly healthier CHF patients compared to the baseline pre-BPCI period. In contrast, there was a significant increase in the severity of patients in PSRI episodes in Model 3 SNFs relative to the baseline period.

Lewin conducted sensitivity analysis to determine if the changes observed in the patient assessment data for SNF MJRLE, SNF SPRI, and HHA CHF explain the significant BPCI impacts on payment and quality for these clinical episodes. They conclude that, even after adjusting for functional status and other characteristics present on admission, the impact estimates remain significant for most outcomes, thereby strengthening the findings that BPCI had an impact on key outcomes.

There was limited use of the various Medicare flexibilities available under BPCI, such as program rule waivers, beneficiary incentives, and gainsharing. Although most BPCI participants indicated to CMS that they wanted program flexibility options, few EIs actually used them. These flexibilities include regulatory waivers (for SNF threeday hospital stay requirement, telehealth geographic restrictions, and direct supervision requirements for post-discharge home visits), in-kind beneficiary incentives, and gainsharing permissions to allow the sharing incentive payments with care partners.

patient was later found to not be in a BPCI episode. Additionally, Model 2 hospitals were more likely to discharge patients home rather than to a SNF. This reason was especially apparent among interviewees participating in orthopedic surgery episodes. Finally, a handful of participants believed that it was not clinically appropriate to discharge some patients (e.g., those with co-morbidities or non-surgical episodes) in less than three days, thus limiting the use of the waiver. *** The BPCI initiative tests a wide range of possible bundled payment configurations: three payment Models and multiple options for interested organizations to participate in up to 48 clinical episodes.

Although the diversity of BPCI allows CMS to relatively quickly assess responses to payment incentives across a range of situations, this strength is also one of the main limitations to a straightforward interpretation of BPCI’s impact to Medicare spending, care delivery, and beneficiary well-being. Since the program’s start, CMS and its contractors have found it challenging to reach conclusions about any overall impact given the varied permutations of providers, patients, and programmatic elements that any given BPCI pilot might have. Nonetheless, BPCI has many important lessons for many stakeholders, especially as CMS plans to expand its scope of voluntary bundled payment programs.

To download the full report, please visit https://downloads.cms.gov/files/cmmi/ bpci-models2-4yr3evalrpt.pdf.

Most BPCI participants stated that they have not used the SNF 3-Day waiver due to their inability in real time to determine which patients were eligible for BPCI. They also expressed concern about the lack of Medicare coverage of the SNF stay if the Flexibility

Uptake by Model 2 EIs

Uptake by Model 3 EIs

Beneficiary incentives

18% offered incentives, out of 49% of Model 2 EIs eligible to do so

5%, out of 71% of Model 3 EIs eligible to do so

SNF 3-day stay waiver

Used for 5% of all SNF episodes. 63% of Model 2 EIs were able to use the waiver.

N/A

Telehealth waivers

5.0%

1.0%

Post-discharge home visits

0.3%

0.1%

Used by 8-18% of EIs

Used by 15% of EIs

Gainsharing

25

ARN DEVELOPS TOOLS AS A GUIDE FOR CONTINENCE CARE

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he Association of Rehabilitation Nurses (ARN) recently unveiled six evidence-based algorithms and additional tools as a standardized guide for continence care at its 2017 annual meeting in Seattle, Washington, USA. ARN developed the clinical tools to address standardized education, policies and procedures on continence care for rehabilitation as well as other nursing care programs.

Over a nine-month period, the ARN’s Continence Care Taskforce reviewed 10 years of bowel and bladder management research.

The result was the development of tools geared towards the interdisciplinary rehabilitation team including six algorithms to assess the most common continence care challenges. The algorithms address:

1.

2.

3.

4.

5.

6.

General Assessment of Bladder General Assessment of Bowel Function Urinary Incontinence Voiding Dysfunction Constipation Diarrhea or Fecal Incontinence.

The taskforce was compelled to develop the tools to help nurses establish effective management plans early enough during the patient’s stay, a process often complicated by “a lack of evidence-based education and use of standards or protocols in rehabilitation settings.” The tools are intended to assist the entire interdisciplinary rehabilitation team with identifying care needs along with supportive tools to improve bowel and bladder management.

More information on the booklet and additional resources is available at www.rehabnurse.org/continencecare.

CMS COMPILES IRF COVERAGE REQUIREMENT CLARIFICATIONS INTO ONE DOCUMENT

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he Centers for Medicare & Medicaid Services (CMS) recently published a document titled, “Clarifications for the IRF Coverage Requirements” to help simplify the high number of subregulatory clarifications it has issued for Medicare Inpatient Rehabilitation Facility (IRF) coverage requirements. The document combines at least nine different clarifications that CMS has issued since 2010 on topics such as documentation requirements, intensity of therapy guidelines, medical necessity standards, physician visits, and several more pertaining to IRF coverage guidelines.

once over the years, and where that occurred, they eliminated the duplications. The agency also says that the document does not provide any new guidance, and only combines previously issued guidance into one document. A review by AMRPA staff also found that no new guidance is found in the document.

CMS states that the document was developed to make it easier for people to find the various clarifications that have been posted to CMS’ website. CMS says in the introduction to the document that some clarifications had been issued more than

https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/InpatientRehabFacPPS/Downloads/Complete-List-ofIRF-Clarifications-Final-Document.pdf

The “Clarifications for the IRF Coverage Requirements” document is available for download from the link below. AMRPA members should contact the AMRPA policy staff if they have any questions about these clarifications.

AMRPA Magazine January 2018

CMS ANNOUNCES 2018 MEDICARE PARTS A AND B PREMIUMS AND DEDUCTIBLES

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he Centers for Medicare & Medicaid Services (CMS) released the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.

Medicare Part A Premiums/Deductibles Medicare Part A covers inpatient hospitals including inpatient rehabilitation stays, skilled nursing facility (SNF), and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017. The Part A deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries must pay a coinsurance amount of $335 per day for the 61st through 90th day of a hospitalization ($329 in 2017) in a benefit period and $670 per day for lifetime reserve days ($658 in 2017).

For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $167.50 in 2018 ($164.50 in 2017).

married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $232 in 2018, a $5 increase from 2017. Uninsured aged and certain individuals with disabilities who have exhausted other entitlement and who have less than 30 quarters of coverage will pay the full premium, which will be $422 a month, a $9 increase from 2017.

Medicare Part B Premiums/Deductibles Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment (DME), and other items. The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. The annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017.

A statutory “hold harmless” provision applies each year to about 70 percent of Part B enrollees. For these enrollees, any increase in Part B premiums must be lower than the increase in their Social Security benefits. After several years of no or very small increases, Social Security benefits will increase by 2.0 percent in 2018 due to the cost of living adjustment. Therefore, some beneficiaries who were held harmless against Part B premiums increases in prior years will have a premium increase in 2018.

The 30 percent of all Part B enrollees who are not subject to the “hold harmless”

Part A Deductible and Coinsurance Amounts for Calendar Years 2017 and 2018

by Type of Cost Sharing 2017

2018

$1,316

$1,340

Daily coinsurance for 61st-90th day

329

335

Daily coinsurance for lifetime reserve day

658

670

164.50

167.50

Inpatient hospital deductible

Skilled Nursing Facility coinsurance Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were

Highlights: •

•

The 2018 Medicare Part A annual inpatient hospital deductible will be $1,340 per benefit period.

The 2018 standard monthly premium for Medicare Part B enrollees remains the same $134.

An estimated 42 percent of all Part B enrollees are subject to the hold harmless provision in 2018 but will pay the full monthly premium of $134, because the increase in their Social Security benefit will be greater than or equal to an increase in their Part B premiums up to the full 2018 amount. About 28 percent of all Part B enrollees are subject to the hold harmless provision in 2018 and will pay less than the full monthly premium of $134, because the increase in their Social Security benefit will not be large enough to cover the full Part B premium increase.

Medicare Part B enrollees not subject to the “hold harmless” provision include beneficiaries who do not receive Social Security benefits, those who enroll in Part B for the first time in 2018, those who are directly billed for their Part B premium, those who are dually eligible for Medicaid and have their premium paid by state Medicaid agencies, and those who pay an income-related premium. These groups represent approximately 30 percent of total Part B beneficiaries.

More information on 2018 Medicare premiums and deductibles is available on the CMS website.

provision will pay the full premium of $134 per month in 2018. Part B enrollees who were held harmless in 2016 and 2017 will see an increase in the monthly Part B premium from the roughly $109, on average, they paid in 2017.

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CMS RELEASES HOSPITAL VALUE-BASED PURCHASING PROGRAM RESULTS FOR FY 2018

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he Centers for Medicare and Medicaid Services (CMS) released the results of the Hospital Value-Based Purchasing Program (HVBP), which adjusts what Medicare pays hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of inpatient care they provide to patients.

Among post-acute care (PAC) providers, Medicare has a pay-for-performance, value-based purchasing program (VBP) for skilled nursing facilities (SNFs) and an active home health VBP model. The Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) is a pay-forreporting program currently, as are the other PAC QRPs. Fiscal Year 2018 Hospital VBP Program For fiscal year (FY) 2018, the HVBP applicable percent reduction (the portion of Medicare payments available to fund the program’s value-based incentive payments) remain at 2 percent of the base operating Medicare Severity DiagnosisRelated Group (MS-DRG) payment amounts for all participating hospitals.

This is the sixth year of the HVBP Program.

Under the program, payments for inpatient stays in approximately 3,000 hospitals will be affected by: •

Hospitals’ performance on healthcare quality and cost measures during a performance period, as compared to their peers.

•

How much hospitals have improved the quality of care provided to patients over time.

For FY 2018, more hospitals will have an increase in their base operating MS-DRG payments than will have a decrease. In total, close to 1,600 hospitals will have a positive payment adjustment. For FY 2018, about half of hospitals will see a small change in their base operating MS-DRG 28

payments (between -0.5 percent and 0.5 percent). After taking into account the 2 percent withhold as required by law, the highest performing hospital in FY 2018 will receive a net increase in payments of slightly more than 3 percent, and the lowest performing hospital will incur a net reduction in payments of 1.65 percent.

The FY 2018 HVBP Program domains for weighting are: •

Clinical Care: 25 percent

•

Safety: 25 percent

•

Patient and Caregiver-Centered Experience of Care: 25 percent

•

Efficiency and Cost Reduction: 25 percent

CMS posted the Hospital VBP incentive payment adjustment factors for each participating hospital for FY 2018 in Table 16B on its FY2018 IPPS website.

New Program Requirements for FY 2019 The measure set for the FY 2019 program year will include a few changes: •

CMS is removing the Patient Safety for Selected Indicators Composite (PSI 90) from the Safety domain.

•

It will add a risk-standardized elective primary total hip arthroplasty and/ or total knee arthroplasty (THA/TKA) complications measure to the Clinical Care domain.

The measurement domains and domain weighting for the FY 2019 Hospital VBP Program will remain unchanged.

Highlight: •

CMS estimates that the total amount available for valuebased incentive payments for FY 2018 discharges will be approximately $1.9 billion.

Performance Score. The actual amount earned back by participating hospitals will depend on: •

Each hospital’s Total Performance Score;

•

Each hospital’s value-based incentive payment percentage; and

•

The total amount available under the program for value-based incentive payments.

Hospitals may earn back a value-based incentive payment percentage that is less than, equal to or more than the applicable percent by which their payments were reduced for that program year. This means hospitals could see an increase, a decrease or no change to their Medicare IPPS payments for the applicable fiscal year. The total estimated amount available for value-based incentive payments for FY 2018 discharges is approximately $1.9 billion.

For more information, see the CMS’ Hospital VBP Program and the QualityNet websites.

Computing the VBP Score The Hospital VBP Program is budgetneutral and funded each year through a reduction of participating hospitals’ base operating MS-DRG payments for the applicable fiscal year. These payment reductions are redistributed to hospitals as incentive payments based on their Total AMRPA Magazine January 2018

GRANT AWARDED TO PROMOTE EXERCISE AND HEALTH AMONG PERSONS WITH DISABILITIES

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grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) at the Administration for Community Living (ACL) has been awarded under the Rehabilitation Engineering Research Centers (RERC) Program for Technologies to Promote Exercise and Health Among People with Disabilities to the University of Alabama at Birmingham (UAB) and the Lakeshore Foundation.

The purpose of the RERC program is to improve the effectiveness of services authorized under the Rehabilitation Act of 1973 by conducting advanced engineering research on and development of innovative technologies that are designed to solve particular rehabilitation problems or to remove environmental barriers. RERCs also demonstrate and evaluate such technologies, facilitate service delivery system changes, stimulate the production and distribution of new technologies and equipment in the private sector, and provide training opportunities.

The project, RERC on Exercise and Recreational Technologies for People with Disabilities, received grant funding for $925,000 per year for five years starting on September 2017.

The awardees will research and develop

projects that span across the socio-ecological model from community to clinic to address a multilevel set of barriers to participation in healthful exercise and recreation among adults with physical disabilities.

The six areas include: 1. A precision-based decision support tool to improve quality of exercise and recreation recommendations and outcomes; 2. Advancement of a wheelchair accessible active video gaming controller to expand game play among users with physical disabilities; 3. Final development of an exercise device that allows single-to-multiple limb loading in engaging virtual exercise environments; 4. A crowdsourcing platform for building accessible community-based exercise and recreation resources; 5. An ehealth tele-exercise platform for increasing exercise among adults with spinal cord injury; and

Highlight: •

The project is to address barriers to participation in healthful exercise and recreation among adults with physical disabilities.

of fitness equipment standards by manufacturers and fitness facility managers.

Anticipated outcomes for the grant include a set of hardware and software products that will improve health, function and quality of life among people with physical disabilities.

They also will work to disseminate products and tools to stakeholders, including persons with disabilities, caregivers, rehabilitation and exercise science researchers, and rehabilitation and exercise professionals, who can use them in their respective communities and professions.

For the announcement, see https://www.acl.gov/news-and-events/ announcements/rehabilitation-engineeringresearch-centers-program-grant-awarded

6. A mixed methods study examining barriers and facilitators associated with adoption of universal design 29

HHS’ LEANING AND ACTION NETWORK ISSUES SECOND REPORT ON APM ADOPTION RATES

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he Health Care Payment Learning and Action Network (LAN) released results of the Alternative Payment Model (APM) Measurement Effort in its 2017 report titled Measuring Progress: Adoption of Alternative Payment Models in Commercial, Medicaid, Medicare Advantage, and Fee-for-Service Medicare Programs. The report found that 29 percent of health care payments in 2016 were made through APMs such as shared savings, shared risk, bundled payments, or population-based payments.

As more payers and integrated health systems move to APMs, providers such as inpatient rehabilitation hospitals and units (IRH/Us) are being asked to demonstrate that they offer high-value and high-quality care.

Background The LAN was launched in March 2015 by the Department of Health and Human Services

30

(HHS) as a public-private partnership to drive adoption and alignment of alternative payment models. It currently has more than 7,100 participants. Since its inception, LAN has adopted the Obama Administration’s goal to shift 30 percent of U.S. health care payments into APMs by 2016 and 50 percent by 2018. The current administration has continued to support efforts to move to value-based payment to date, as evidenced by its ongoing sponsorship of the LAN. The report marks the second year of the LAN APM Measurement Effort and captures data from calendar years (CYs) 2015 and 2016 to date from several payer sources: America’s Health Insurance Plans (AHIP), the Blue Cross Blue Shield Association (BCBSA), and the Centers for Medicare and Medicaid Services (CMS) across commercial, Medicaid, Medicare Advantage (MA), and fee-for-service (FFS) Medicare market segments. The payments are then categorized according to the

Highlight: •

The LAN found that 29 percent of nation’s health care payments are tied to alternative payment models in 2016, up from 23 percent in 2015.

four categories of the original LAN APM Framework.

•

Category 1: Traditional fee-for-service or other legacy payments not linked to quality

•

Category 2: Pay-for-performance or care coordination fees

•

Category 3: APMs built on fee-forservice architecture (shared savings, shared risk, bundled payments)

•

Category 4: Population-based payments AMRPA Magazine January 2018

Payment Year

Cat1

Cat2

Cat 3&4

Data Sources

Lives (#)

Covered Lives (%)

2016

43%

28%

29%

78 plan, 3 managed FFS Medicaid states, FFS Medicare

245.4 mil

84%

2015

62%

15%

23%

70 plans, 2 managed FFS Medicaid states

198.9 mil

67%

Results The results show that the nation has nearly met the LAN’s goal of 30 percent of payments tied to APMs, compared to 23 percent the previous year. The latest 2016 look-back results were based on data from more than 80 payer participants and accounted for nearly 245.4 million people (or 84 percent of the covered U.S. population).

Across commercial, MA, Medicare FFS and Medicaid payers: •

43 percent of health care dollars are in Category 1 (e.g., traditional FFS or other legacy payments not linked to quality)

•

28 percent of health care dollars in Category 2 (e.g., pay-forperformance or care coordination fees)

•

29 percent of health care dollars in a composite of Categories 3 and 4 (e.g., shared savings, shared risk, bundled payments, or populationbased payments)

This represented a shift from FFS payments and growth in Category 2, and a 6 percent increase in Categories 3 and 4 APM payments, bringing total APM spending to approximately $354.5 billion dollars nationally. The table below compares the results from the 2015 and 2016 payment years.

Interpreting the Results The report points to several factors for the increase in APM adoption from 2015 to 2016: Increased Accountable Care Organization (ACO) Penetration The increase in accountable care organizations (ACOs) in both the public and private sectors was one reason for greater APM adoption. Medicare has launched its Next Generation ACO program, and more health care entities have also joined the Medicare Shared Savings Program (MSSP). The LAN also found that in the private sector, 92 organizations became ACOs from the first quarter of 2016 to the first quarter of 2017, bringing the nationwide total to 923.

Legislation The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established significant financial incentives for physicians to participate in Advanced APMs. These incentives have likely accelerated participation in advanced APMs within Categories 3 and 4. Many providers who do not exceed the minimum threshold of Advanced APM participation to qualify for MACRA incentives will be paid through the Meritbased Incentive Payment System (MIPS) in 2019, which will likely extend this trend.

FFS Medicare Impact The growth in Category 2 payments is attributable in part to the inclusion of FFS Medicare data in the measurement effort. The HVBP programs and other value-based programs administered by Medicare are considered Category 2 APMs. The report concludes that the LAN APM Measurement Efforts demonstrate significant progress being made by private and public payers in moving to APMs. The LAN plans to conduct another evaluation next year which will capture CY 2017 data and incorporate changes seen in primary care payments due to patient-centered medical homes and the Comprehensive Primary Care Plus Model (CPC+).

The full report can be downloaded at https://hcp-lan.org.

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IMPLANTABLE MUSCLE STIMULATOR DEVICE AIMS TO BENEFIT PATIENTS WITH SPINAL CORD INJURIES

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he U.S. Department of Defense (DoD) issued a $1.8M three-year grant to develop an implantable muscle stimulator for preventing pressure ulcers and deep tissue injuries for patients with spinal cord injuries. Pressure ulcers are caused by lying or sitting in one place for long periods of time and can lead to severe pain and infection, even death.

In spinal cord injury (SCI) cases, motor impairment causes muscle atrophy that changes both muscle quantity and quality, increasing the risk of pressure ulcers and deep tissue injuries. The only way to heal is to stay off the injured area, which can lead to weeks or even months of bed rest, significantly reducing quality of life.

Patients are often unable to sustain regular employment or take part in community life, resulting in emotional distress and care is often costly and time intensive.

A research team from Case Western

32

Reserve University and other institutions collectively developed and tested flexSTIM, a small, flexible, fully implantable stimulator with electrodes that, at the touch of a button, will provide intermittent stimulation to the three gluteal muscles that comprise the buttocks. By mimicking regular weight-shifting – consequently increasing muscle bulk – the stimulation seeks to improve muscle health and help prevent pressure ulcers and deep tissue injuries.

The researchers had previously tested a system that provided intermittent stimulation in five spinal cord injury patients, but it was not fully implantable.

Although the system helped patients regain healthy skin tissue and gluteal muscle mass, and not develop pressure ulcers, the system’s mechanical design was susceptible to infection.

The benefits of the new fully implanted system include improved quality of life and

Highlight: •

Benefits of the new fully implanted system are to increase quality of life and decrease cost of medical care for spinal cord injury patients.

decreased cost of medical care. Risks will be minimized because only a small incision will be needed to implant the 4mm thick device. Whereas current commercially available stimulators require major surgery and are limited to certain areas of the body such as the abdomen, flexSTIM implantation can be done in an outpatient procedure and only require local anesthesia. However, the development is in relative nascence – the researchers expect to conduct human clinical trials of the device within five years and begin marketing within 10 years.

AMRPA Magazine January 2018

CHALLENGES REMAIN IN THE COLLECTION OF MEDICARE OVERPAYMENTS BY ZPICS AND PSCS, OIG SAYS

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he Department of Health and Human Services (HHS) Office of Inspector General (OIG) is continuing its examination of Medicare overpayments in a second report titled, Enhancements Needed in the Tracking and Collection of Medicare Overpayments Identified

By ZPICs And PSCs. The report is an update on the collection rate of overpayments identified by zone program integrity contractors (ZPICs) and program safeguard contractors (PSCs), and identifies contractors’ ongoing challenges in collecting and tracking overpayments.

AMRPA has heard from members that it is similarly challenging for providers to track Medicare contractors’ activities and it is highly burdensome to providers as well.

HHS employs various ways to identify Medicare overpayments to providers, primarily through Medicare contractors, with the goal of reducing improper payments overall. However, past OIG work has found that overpayments referred by program safeguard contractors for collection did not result in significant recoveries to the Medicare program.

As of 2012, the Centers for Medicare & Medicaid Services (CMS) transitioned the workload of most PSCs to six ZPICs. In 2016, CMS began transitioning the remaining PSCs and ZPICs to unified program integrity contractors (UPICs).

OIG’s work on both PSCs and ZPICs identified deficiencies in how contractors were tracking and reporting overpayment data.

1. The number and amount of Medicare overpayments that ZPICs and PSCs referred to Medicare administrative contractors (MACs) for collection in fiscal year (FY) 2014.

OIG’s Findings

2. The collection rate of Medicare overpayments sought by MACs based on referrals from ZPICs and PSCs in FY 2014.

•

3. How ZPICs, PSCs and MACs track Medicare overpayment referrals and collections.

Background ZPICs and PSCs may identify overpayments during the course of their work and are required to refer them to MACs for collection. Overpayments are payments made to providers in excess of amounts properly payable under Medicare statutes and regulations.

An overpayment referral that a ZPIC or PSC sends to a MAC for collection may include multiple claims for service, i.e., the amount in a single referral may represent overpayments made to a provider for multiple claims. The ZPIC or PSC also may extrapolate overpayment amounts based on a sample of the provider’s claims. Although ZPICs and PSCs refer overpayment amounts to the MACs, the MACs make the final determinations of the dollar amounts to be collected from providers.

This study focused on overpayments that ZPICs and PSCs sent to MACs for collection in fiscal year (FY) 2014.

Findings •

In this study, determine:

the

OIG

sought

to

ZPICs and PSCs referred $559 million in overpayments to MACs in 2014, however, the dollar amounts

•

ZPICs, PSCs and MACs continue to experience challenges in tracking referrals and collections of overpayments.

The number and amount of overpayment referrals reported

by ZPICs and PSCs often did not match what was reported by MACs.

referred varied widely across ZPICs and PSCs. In FY 2014, ZPICs and PSCs referred 4,058 overpayments, totaling $559 million, to MACs for collection. Across the ZPICs and PSCs, referral amounts in FY 2014 ranged from $3.5 million to $159 million. Referrals from two ZPICs— ZPIC 5 and ZPIC 7—accounted for half of the total overpayment dollars referred. Combined, these two ZPICs referred a total of $283 million in overpayments to the MACs. The study found substantial variation across ZPICs and PSCs in the amount of overpayments they referred, even after adjusting for differences in oversight responsibility, i.e., the dollar amount of paid claims for which a given ZPIC has oversight. ZPICs’ and PSCs’ respective oversight responsibilities in FY 2014 ranged from $1.4 billion to $63.9 billion.

Under their fee-for-service task orders, ZPICs and PSCs referred between $77 (NE BISC) and $4,204 (ZPIC 7) per $1 million in oversight responsibility. There also was substantial variation in the amount 33

of overpayments ZPICs and PSCs referred for all task orders, even after adjusting for differences in the amount that ZPICs and PSCs were paid to perform their tasks.

•

•

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MACs did not collect 80 percent of the $482 million they sought to collect from ZPICs’ and PSCs’ overpayment referrals in 2014.

Of the overpayments referred by ZPICs and PSCs in FY 2014, MACs sought to collect $482 million from providers. As of September 2015 however, MACs had collected only $96 million, or 20 percent. While this is an increase from the 7 percent collection rate that OIG reported in 2010, MACs did not collect 80 percent of overpayment dollars sought for collection based on ZPIC and PSC referrals.

ZPICs, PSCs and MACs continue to experience challenges in tracking referrals and collections of overpayments.

Tracking referrals continues to present a challenge for the ZPICs, PSCs and MACs. In previous reports, OIG has highlighted problems with the tracking of overpayment referrals and

collections. Specifically, OIG found that MACs could not provide data for 26 percent of the overpayments referred by the PSCs in 2007.

In addition, OIG has previously reported issues with overpayment reporting that made it difficult for ZPICs to track collections on their overpayment referrals, some of which still persist among the current ZPICs, PSCs and MACs.

CMS did not concur or non-concur with this recommendation; it stated that it is evaluating how to effectively implement the surety bond requirement while avoiding undue provider burden.

The full report can be found on OIG’s website.

OIG’s Recommendations The OIG recommends that CMS identify and implement strategies to increase the identification of overpayments as well as the MACs’ collection of ZPIC- and UPICreferred overpayments. The OIG also recommended that CMS implement the surety bond requirement for home health providers and consider surety bonds for other providers based on their level of risk in order to increase collections.

Furthermore, the OIG recommended that CMS improve the ability of ZPICs, UPICs and MACs to track overpayment referrals and collections by creating a standard report format for all contractors and requiring the use of a unique identifier for each overpayment. CMS concurred with all of OIG’s recommendations except the one regarding surety bonds.

AMRPA Magazine January 2018

STUDY EXAMINES THE ASSOCIATION OF THE HOSPITAL READMISSIONS REDUCTION PROGRAM WITH READMISSION AND MORTALITY OUTCOMES IN HEART FAILURE

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ublic reporting of hospitals’ 30day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences according to a study published in the November issue of JAMA Cardiology.

The authors sought to examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry.

Methods The study cohort included 115,245 feefor-service (FFS) Medicare beneficiaries across 416 U.S. hospital sites participating in the American Heart Association’s Get with the Guidelines-Heart Failure registry. Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from Jan. 1, 2006, to Dec. 31, 2014. The main outcome and measures included riskadjusted 30-day and one-year all-cause readmission and mortality rates.

Results The mean age of the study population (n = 115,245) was 80.5 (8.4) years, 62, 927 (54.6 percent) were women, and 91, 996 (81.3 percent) were white and 11, 037 (9.7 percent) were black. The 30-day risk-adjusted readmission rate declined from 20.0 percent before the HRRP implementation to 18.4 percent in the HRRP penalties phase (hazard ratio (HR) after vs. before the HRRP implementation, 0.91; 95 percent CI, 0.87-0.95; P < .001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2 percent before the HRRP implementation to 8.6 percent in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95 percent CI, 1.10-1.27; P < .001). The one-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The one-year riskadjusted readmission rate declined from 57.2 percent to 56.3 percent (HR, 0.92; 95 percent CI, 0.89-0.96; P < .001), and the oneyear risk-adjusted mortality rate increased from 31.3 percent to 36.3 percent (HR, 1.10; 95 percent CI, 1.06-1.14; P < .001) after vs before the HRRP implementation.

Findings The study found that implementation of the HRRP was temporarily associated with a subsequent decrease in 30-day and one-year risk-adjusted readmissions,

Highlight: •

The HRRP program was temporarily associated with a decrease in 30-day and one-year risk-adjusted readmissions, but also an increase in 30-day and one-year risk-adjusted mortality.

but also an increase in 30-day and oneyear risk-adjusted mortality. The authors concluded that this supports the possibility that the HRRP has had the unintended consequence of increased mortality in patients hospitalized with heart failure.

Citation Ankur Gupta, Larry A. Allen, Deepak L. Bhatt, Margueritte Cox, Adam D. DeVore, Paul A. Heidenreich, Adrian F. Hernandez, Eric D. Peterson, Roland A. Matsouaka, Clyde W. Yancy, Gregg C. Fonarow.

Association of the Hospital Readmissions Reduction Program Implementation with Readmission and Mortality Outcomes in Heart Failure. JAMA Cardiol. Published online November 12, 2017. doi:10.1001/ jamacardio.2017.4265.

For the abstract, see https://jamanetwork. com/journals/jamacardiology/articleabstract/2663213

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AMRPA SUBMITS FEEDBACK ON CMMI’S NEW DIRECTION TO TRANSFORM HEALTH CARE DELIVERY Editor’s Note: On November 20, 2017, the American Medical Rehabilitation Providers Association (AMRPA) submitted feedback to the Center for Medicare and Medicaid Innovation’s (Innovation Center) Request for Information (RFI) on its new direction to adopt a more affordable and accessible health care system. The letter addresses the six guiding principles in the RFI and proposes solutions to the statutory and regulatory obstacles facing providers of medical rehabilitation care. The complete letter is provided below and is available at www.amrpa.org.

November 20, 2017 Amy Bassano Acting Director for the Center for Medicare and Medicaid Innovation Acting Deputy Administrator for Medicare Innovation and Quality Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Re: Centers for Medicare and Medicaid Services Innovation Center New Direction Request for Information

O

n behalf of the American Medical Rehabilitation Providers Association (AMRPA), we write in response to the Center for Medicare and Medicaid Innovation’s (Innovation Center) Request for Information (RFI) seeking feedback on a new direction to foster an affordable and accessible health care system that puts patients first. AMRPA appreciates the Innovation Center’s solicitation of comments for Medicare innovations from those who know the landscape best: health care providers. We believe that proactive stakeholder engagement of this nature will pay dividends in promoting patient-centered care and testing reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes.

AMRPA is the national voluntary trade association representing more than 600 freestanding rehabilitation hospitals and rehabilitation units of general hospitals (collectively referred to by Medicare as inpatient rehabilitation facilities, or IRFs), outpatient rehabilitation service providers, long-term care hospitals (LTCHs), and several skilled nursing facilities (SNFs). IRFs provide hospitallevel care, which is significantly different in intensity, capacity, and outcomes from post-acute care provided in non-hospital settings.

AMRPA members help their patients maximize their health, functional ability, independence, and participation in society so they are able to return to home, work, or an active retirement.

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The majority of our members are Medicare participating providers and, on average, Medicare Part A payments represent more than 60 percent of IRF revenues. In 2015, IRFs served approximately 344,000 Medicare beneficiaries, representing more than 381,000 IRF stays. Hence, any alterations to the Medicare payment system have significant implications for these medical providers.

AMRPA shares the agency’s goal of transforming the health care delivery system to streamline administrative processes and put patients back at the center of their own care. To that end, the proposals below seek to address CMS’ request for ideas on new innovation models that meet the six guiding principles, as well as propose solutions to longstanding and worsening statutory and regulatory obstacles that providers of medical rehabilitation care must overcome to deliver patient-centric, high-quality, efficient post-acute care. In confronting these obstacles, we offer specific proposals to reduce burdens on IRFs, enhance quality of care, decrease costs, and ensure that patient and provider decisions are informed by clinical judgment and best practices in the patient’s best interest, rather than arcane bureaucratic policies.

I. Innovation Models AMRPA broadly supports the Innovation Center’s efforts to explore new directions in innovation by considering additional types of models.

A. Implementing the Continuing Care Hospital (CCH) Model One highly promising model is the continuing care hospital (CCH), which would go beyond the incremental and indirect approaches to managing post-acute care to date. Most current models seek to bundle post-acute care into an episode that starts with an acute hospitalization, thus treating all beneficiaries generally the same by squeezing as much service and care delivery out of the episode as feasible. The CCH takes a very different approach by putting the patient at the center of his or her own care and creating efficiencies by tailoring post-acute care only to that patient’s needs and not arbitrary requirements tied to a particular site of service. By allowing patients to “transition” post-acute care settings without requiring a physical transfer, post-acute care is more contiguous, less fragmented, and ultimately both more resource-efficient and patient-centric. By allowing networks of providers to form a CCH physically or virtually, the CCH mirrors other successful models that afford providers the necessary flexibility to deliver highly efficient health care.

Congress statutorily directed the Innovation Center to test the CCH model , but the prior Administration declined to do so. The model is not only a compelling alternative payment model (APM) AMRPA Magazine January 2018

but a promising care delivery system reform that would foster better, more coordinated, patient-centric care and disincentivize costly, disruptive and needless transfers. The CCH should be implemented, as it would create important efficiencies, reduce administrative costs, and ultimately improve the lives of patients.

As noted, CMS does not require any additional authorizing legislation or appropriations to proceed to launching the CCH model, which the agency is already statutorily mandated to do.

AMRPA has previously submitted the CCH model for the Innovation Centerâ&#x20AC;&#x2122;s consideration under the Health Care Innovation Awards (HCIA) Round 2 application process. We believe the model continues to be highly relevant and highlight below its alignment with the Innovation Centerâ&#x20AC;&#x2122;s guiding principles as outlined in the RFI. 1. Choice and Competition in the Market: Promote competition based on quality, outcomes and costs.

The CCH would incentivize market-level providers to deliver post-acute care in a way that achieves high quality and durable patient outcomes in a cost-effective manner. The CCH recombines the post-acute care services that over time, have devolved to the less efficient, less effective system present today. These systems have each developed in response to past cost containment efforts and legislative changes, but they also have evolved separately, using different case-mix systems to measure the same types of conditions, depending on the site of care. The incentives also have evolved over time so that a post-acute care episode of care now consists of multiple different admission and discharge tools and processes, each with their own reporting requirements, admitting practices, electronic record systems, and treatment teams.

2. Provider Choice and Incentives: Focus on voluntary models, with defined and reasonable control groups or comparison populations, to the extent possible, and reduce burdensome requirements and unnecessary regulations to allow physicians and other providers to focus on providing high-quality healthcare to their patients. Give beneficiaries and healthcare providers the tools and information they need to make decisions that work best for them.

The CCH is a voluntary model and is comprised of a defined test group (post-acute care providers electing to participate in the model) and control group (fee-for-service providers). Its success is built on eliminating the current post-acute care silos established by the fractured Medicare payment and regulatory systems governing post-acute care settings, and the overall post-acute care delivery system.

3. Patient-Centered Care: Empower beneficiaries, their families, and caregivers to take ownership of their health and ensure that they have the flexibility and information to make choices as they seek care across the care continuum.

The CCH is a patient-centered care model in which care is delivered based on patient need, rather than setting. This provides an opportunity for CMS to realize cost savings due to efficiencies, and for patients to achieve better outcomes due to improved care coordination and minimized patient transfer among post-acute care settings. The CCH organizes care around the patient instead of the provider by consolidating

currently disparate levels of post-acute care into a single enterprise with a single treatment team, single case-mix adjusted payment system, single admission/discharge, and unified method for measuring quality.

4. Benefit Design and Price Transparency: Use data-driven insights to ensure cost-effective care that also leads to improvement in beneficiary outcomes.

The goals of the CCH are to improve the continuity of care, improve quality of care and beneficiary outcomes, and increase efficiencies by achieving the following. a. Improve continuity of care: i. Continued treatment by the same clinical team (physicians, nurses, therapists, among others) as the patient improves; ii. Improved communication about patient needs with the patient and family; and iii. Reduce complications associated with transfers of the patient. b. Improve quality of care and outcomes: i. Reduce medical complications; ii.

Reduce probability of hospital readmissions/ emergency room visits; iii. Improve functional outcomes at the end of the episode; and iv. Improve communication and follow-up post-discharge from post-acute care. c. Increase efficiencies: i. Reduce administrative costs of admissions/discharges between post-acute care providers associated with system paperwork, administrative burden, and patient transfers; ii. Reduce duplicative patient assessments at admissions, information transfer, tests, lab work, and pharmacy reconciliations; and iii. Reduce discharge planning costs.

5. Transparent Model Design and Evaluation: Draw on partnerships and collaborations with public stakeholders and harness ideas from a broad range of organizations and individuals across the country.

The CCH is built on a strong foundation of market-level partnerships among providers that would allow them to create a physical or virtual entity capable of delivering post-acute care in a unified manner. Robust engagement and communication among model participants and their partners is critical to the success of the CCH. At the time of AMRPAâ&#x20AC;&#x2122;s HCIA application, 18 hospital providers voluntarily stepped forward to participate in the model and submitted application forms with their data, proposed approaches and identified their target beneficiary populations. These volunteer sites also submitted Letters of Support from post-acute care provider partners in their respective geographic areas documenting their community support and outreach.

6. Small Scale Testing: Focusing on key payment interventions rather than specific devices or equipment.

As described above, the CCH model fits the parameters of small scale testing because its framework is built on marketlevel provider organizations with the ability to innovate post37

acute care delivery due to Medicare’s payment interventions and regulatory flexibilities.

When originally announced, CMS stated there would be eight models in the BPCI.

The greatest opportunity to revolutionize post-acute care is a CCH approach that smooths care transitions and integrates what are otherwise isolated interventions. This approach parallels recent deliberations by the Medicare Payment Advisory Commission (MedPAC) examining ways to eliminate physical and regulatory barriers between care settings and avoiding disruptive care transitions. Several Commissioners have expressed support for payment models that would allow a patient to be treated at different acuity levels of care without having to be discharged from one provider entity to another, akin to how patients move around an acute care hospital (e.g., intensive care, cardiac care units). To that end, AMRPA has been working to develop a CCHlike payment and delivery model, known as the Continuing Care Network (CCNet), to test in partnerships with Medicare managed care organizations and the continuum of post-acute care providers. This initiative is discussed further in section IV.B. below.

One of the next four models would be focused on a prospective payment approach for post-acute care only. We are particularly interested in seeing that model implemented given our interest in the CCH. We also recommend that any new models within BPCI should assure that inpatient rehabilitation services are included in such a bundle. Furthermore, if the Innovation Center pursues an episode-based approach to bundled payment via BPCI or another program, AMRPA again urges that any such models must include IRF services in the definition of the episode.

AMRPA is eager to collaborate with the Innovation Center on how to bring the CCH model into fruition and truly reform postacute care delivery and payment.

B. Continuation of the CMS Bundled Payment Care Improvement (BPCI) Initiative CMS is in the fourth year of the Bundled Payment Care Improvement (BPCI) Initiative. The project currently has three active models (Models 2-4), two of which include post-acute care. Model 2 focuses on acute and post-acute care and Model 3 focuses exclusively on post-acute and hence is more similar to the CCH model discussed above though not as comprehensive.

The BPCI payment structure implemented to date is based on current fee-for-service models with adjustments. While we strongly urge the implementation of the CCH Model above, CMS should not lose sight of the experience being gained via the BPCI models. Hence, we support their continuation and expansion and look forward to CMS’ anticipated announcement of BPCI Advanced. We wish to express our strong desire to see the BPCI Advanced program designed in a fashion that offers post-acute care providers opportunities to play a central role in innovative care models.

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From the patient’s perspective, the value of their care is neither defined by nor confined to the parameters of a 30 or 60-day bundle, but is in the quality of their rehabilitation, return to functional well-being and long term recovery. We urge CMS to be equally comprehensive in its view on value and the return on Medicare’s investment. As the agency is well-aware, there is compelling evidence that post-acute care site of service decisions can have profound long-term consequences when patients are not treated in the most medically appropriate setting. It would be myopic for the agency to focus only on Medicare expenditures within a government-defined episode of care and not account for the significance of such important patient outcomes that bear out over time, including improved functional outcomes, lower readmissions and mortality rates, and more days spent in the community.

II. Expanding Opportunities to Participate in Advanced APMs and Market-Based Innovations A. Alternative Flexibility

Reimbursement/Pricing

and

Regulatory

The RFI announces the prioritization of two interrelated objectives: expanding opportunities to participate in Advanced APMs; and fostering market-based approaches to health care innovation.

Both of these aims are advanced by a proposal AMRPA has long advocated: affording providers a greater degree of pricing flexibility when participating in APMs. CMS has encouraged IRFs to participate in APMs. However, Medicare reimbursement for IRF services is incredibly rigid, with a fixed per-discharge prospective payment system based largely on factors outside of the IRF’s control (e.g., principal diagnosis in the preceding hospitalization). In contrast, other post-acute care providers such as nursing home and home health providers have a greater degree of control over their Medicare charges, namely through reducing lengths of stay under a per diem payment system. Thus, IRFs are encouraged to participate in models in which their services are part of a broader bundle, but are not given sufficient flexibility to control the resources that are utilized under the bundle. As an example of Market-Based innovations, the RFI suggests allowing providers to offer bundled payments for full episodes of care with groups of providers bidding on the payment amount or by launching preferred provider networks.

In such a scenario, IRFs should be able to be responsive to such consumer-directed approaches and not be constrained by an inelastic Medicare fee structure that would effectively price them AMRPA Magazine January 2018

out of any episodic/bundled payment model or exclude them from preferred provider networks.

IRFs are eligible participants of several models within BPCI, are encouraged to be collaborators in the mandatory Comprehensive Care for Joint Replacement (CJR) model, and play an active role in other demonstrations and pilots. In addition to pricing, CMS and the Innovation Center clearly have the regulatory authority to waive all of the offending requirements in the context of these models, and have made similar concessions for other providers. For example, in the context of other APMs such as accountable care organizations (ACOs) as well as the CJR, CMS has waived significant regulations such as the well-established rule necessitating a minimum three-day inpatient stay prior to covered skilled nursing facility services. Nevertheless, the agency has been unwilling to waive certain regulatory requirements that must be relaxed to facilitate IRF participation in these programs.

Accordingly, various regulatory requirements should be waived in the context of specific APMs to allow IRFs to participate.

1. Alternative Reimbursement/Pricing: An increasing number of APMs hold provider entities, such as acute care hospitals or broader networks of providers, responsible for post-acute spending. These models encourage IRFs, like other post-acute care providers, to produce high-quality outcomes at a reduced cost. However, unlike other post-acute providers such as nursing homes, IRFs are paid on a flat per-discharge basis for patients.

Because Medicare rules do not allow IRFs to “charge less” in this context, existing bundling programs typically incentivize bundle-holders to steer patients away from receiving inpatient medical rehabilitation, even when it is imperative to their recovery. This phenomenon is exacerbated by these programs’ failure to penalize for stinting on medically necessary care or otherwise measure long-term functional outcomes. For IRFs to be able to compete alongside other providers in these models, willing participants must be permitted to receive reduced reimbursement, a per diem payment, or offer a discount from the IRF PPS amount, if they so choose. Although this likely means that IRFs will be paid below cost for treating patients in these programs, the alternative—that patients are denied access to inpatient rehabilitation altogether—is far worse for IRFs, and especially for patients. Since margins are very small or negative for the majority of IRFs, pricing flexibility must be voluntary, as should all alternative payment and delivery models being tested.

2. Regulatory Flexibility: It is critical for IRFs to have sufficient regulatory flexibility to ensure they are able to deliver the appropriate care in this context. Providers opting for reduced reimbursement for patients associated with non-CMS 13 (i.e., non-60 Percent Rule compliant) cases should be allowed to include those cases from the calculation used to determine the threshold compliance. For example, if an IRF treats a patient who satisfies the 60 Percent Rule at lower pricing under an APM, the patient should “count” toward satisfaction of the rule.

Advances in medicine over the past four decades have allowed individuals with other serious diagnoses, such as cancer and organ failure, to not only survive acute care episodes but benefit tremendously from the intensive, multidisciplinary rehabilitation program provided in IRFs. However, patients

requiring IRF care in categories such as cardiac, pulmonary, oncology, and transplantation, among others, are often denied admission because they do not count toward 60 Percent Rule compliance. In addition to imposing enormous administrative burden on IRFs and the agency, the 60 Percent Rule both impedes access to medically necessary, life-altering rehabilitation care without providing any benefit to patients or providers.

Additionally, the IRF intensity of therapy standard should be relaxed for these cases. Specifically, the so-called 3-Hour Rule (which CMS has interpreted to rigidly require three hours of intensive individualized therapy each day a patient is in an IRF) should not apply to APM cases for which the IRF has elected to receive reduced reimbursement.

These approaches are consistent with CMS’ recent emphasis on expanding provider access to APMs, and has been favorably discussed by MedPAC in the context of the uniform post-acute payment system. CMS has the authority to permit such flexibility, and to waive these bureaucratic requirements without Congressional approval; the agency should do so when promulgating any future models or changes to the current programs.

3. Program Integrity: Administrative Presumption of Coverage under APMs: All patients admitted to IRFs from acute care hospitals participating in an APM, regardless of whether the facility is receiving IRF PPS or reduced reimbursement, should be presumed to be covered in the IRF setting. Acute hospital “bundle holders” are responsible for the cost and quality of care for their bundled patients. If acute care physicians choose to discharge patients to an IRF, they should have full discretion to do so without Medicare contractor interference as their performance metrics and outcomes in the APM will be impacted by the placement decision. CMS should instruct its contractors to respect post-acute care referrals and admission determinations under APMs. Specifically, CMS’ contractors should not be permitted to deny payment for cases treated under APMs based on pre-payment review or post-payment reopening, unless there is evidence of fraud.

AMRPA members welcome the opportunity to participate and play a central role in patient-centered innovation models that incentivize delivering high quality patient outcomes in a cost-effective manner. In our view, the regulatory and payment flexibilities outlined above are fundamental first steps to broadening the base of providers who are able to participate in CMS’ alternative payment models.

III. Quality As the Innovation Center considers ways to promote marketlevel competition, we remind it that, fundamentally, quality measurement should encourage all providers to prioritize quality of care and patient-centric outcomes, rather than utilization management. Safeguards are needed to ensure that quality of care and patient engagement are not sacrificed to reduce costs. Any models or interventions should be supported by a strong quality program with metrics that counterbalance 39

financial incentives to reduce care, as well as promote positive and long-lasting outcomes, avoid potential adverse events, and demonstrate effectiveness and efficiency of care. The measures and their timeframes should assess not only immediate patient safety, but also longer-term indicators of recovery and well-being.

Short of that, any “innovation” may lack the adequate protections against delaying or withholding medically necessary care. Attention must be taken in designing quality programs to ensure that any bias against caring for the most medically complex patients is removed and that there are no incentives to stint on care. Furthermore, measures of performance and impact should be meaningful, actionable, and transparent to consumers, patients, family caregivers, and other stakeholders.

As an example, any preferred provider networks should be required to disclose to beneficiaries information on the quality of care offered by any provider within the network.

IV. Medicare Advantage Innovation With an ever-growing proportion of Medicare beneficiaries enrolled in Medicare Advantage (MA), it is imperative that managed care be part of any holistic efforts to reform the health care system. Thus, we believe the RFI does well to focus on MA innovation models as part of the broader search for meaningful payment and care delivery reforms. Based on collaborative work that AMRPA has undertaken with the private sector which we discuss below, we believe there is tremendous potential to enhance post-acute care delivery within managed care. We hope to expand this work to additional private sector partners but in the meantime, there is much CMS and the Innovation Center can do to facilitate greater flexibility for MA plans to partner with their provider networks to structure care in ways that better meets their enrolled population’s specific needs. Such regulatory flexibility must include the ability to relax certain outdated and needless Medicare requirements on various providers.

the study authors to question whether current MA policies are designed to meet the needs of enrollees who use post-acute and long-term care.

Unfortunately, within the MA program there are significant—often insurmountable—administrative hurdles to getting patients the post-acute care they need. Enrollees are frequently told that their MA coverage does not cover inpatient medical rehabilitation or plans erect other determination and appeals processes that are almost impossible to navigate as a hospitalized patient.

As a result, MA enrollees currently utilize IRF services at a rate substantially below the norm – between one-half and one-third of traditional fee-for-service beneficiaries.

Instead of following Medicare IRF coverage criteria, today many MA plans improperly apply private, proprietary decision tools to make coverage decisions that override shared patient and clinician decision-making, both prospectively and retrospectively.

This practice inappropriately denies claims for IRF-level care and diverts patients who qualify for inpatient rehabilitation to clinically inappropriate lower-acuity settings, decreasing their prospects for full recovery. MA plans have established onerous requirements to seek redeterminations of these initial preauthorization denials and perpetuate delays in the process with limited hours, unqualified review personnel, and lengthy review periods. As a result, many Medicare patients, especially inpatients, lack a meaningful opportunity for appeal.

Regulatory simplification is needed in this area, but flexibility (i.e., waiving needless regulations) must be done with precision and not at the expense of enrollees’ access to care; it should instead be used to their benefits. Flexibility that ensures medical decisionmaking is guided by patients—along with their caregivers and physicians—puts patients themselves back at the center of their care, rather than blanket bureaucratic policies, regardless of whether they are written by CMS or managed care organizations.

A. Approaches to Improve MA Enrollee Access to Care

B. Continuing Care Network Pilot

Efforts to enhance regulatory flexibility in MA must appreciate the current environment of the program and must not compromise beneficiary access to the services to which they are legally entitled. Rather than relegate patient-physician decision making, new initiatives should empower MA enrollees with better tools to make more informed decisions with the help of caregivers and providers.

AMRPA has been working to develop a new post-acute care payment and delivery model, known as the Continuing Care Network (CCNet), to test in partnerships with Medicare managed care organizations and post-acute care providers across the continuum, including IRFs, skilled nursing facilities (SNFs), longterm care hospitals (LTCHs), home health agencies (HHAs), and outpatient providers and clinics. The goal of the CCNet model for payment and care delivery is to break down the current silos and create a full-spectrum post-acute care network that takes a patient-focused approach and realigns incentives to improve outcomes. This approach aligns with the broader evolution in health care of moving toward unified payments that assess outcomes based on both total quality and costs of care. Pursuant to the objectives and requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, CMS and MedPAC have already begun exploring post-acute care payment and delivery reforms.

Independent researchers recently found that MA plan benefits are not designed to adequately meet enrollees’ post-acute and long-term care needs, and that post-acute provider networks and cost-sharing restrict access to needed care. The study’s authors identified these practices as driving a unidirectional flow of higher-cost enrollees from MA back into traditional fee-for-service Medicare. While Medicare beneficiaries who do not utilize postacute care switch between traditional fee-for-service and MA at approximately the same rate, those with even modest postacute care utilization are significantly more likely to switch out of MA than to switch into it, and those with substantial post-acute care utilization are six times more likely to switch to traditional Medicare than into MA. These dramatic findings prompted 40

The CCNet is a collaborative model that utilizes a patientfocused approach to coordinating and delivering care, while reducing costs and improving patient outcomes. The CCNet AMRPA Magazine January 2018

will support changes in the post-acute care model, enabling innovation around topics such as telemedicine and alternative settings for services. The pilot program will initially focus on MA enrollees who have experienced a stroke or lower extremity fracture, and require post-acute care after discharge from an acute hospital setting. In the CCNet, the patient will be the center of decision-making, and care coordination will occur across the post-acute care continuum to ensure that each patient receives the appropriate level of service at the appropriate time based on their individual needs, goals, and preferences, as informed by clinician judgment.

AMRPA is eager to work with the Innovation Center to discuss how the CCNet model could be adopted to meet CMS’ parameters for test models.

V. Good Governance A. Establishing a Post-Acute Care Advisory Council In order to effectuate some of the most promising and lasting reforms to Medicare payment systems, and to the broader health care delivery system, CMS and the Innovation Center need additional opportunities to consult with clinicians and other experts who are closest to the care delivery. AMRPA believes that formalizing some of this infrastructure would benefit the Innovation Center and the quality of the models it generates. The absence of a standing body with expertise in medical rehabilitation, in particular, has caused some foreseeable regulatory oversights. The creation of a Post-Acute Care Advisory Council would allow issues relating to Medicare payment models for post-acute rehabilitation services to be informed by experts in the field.

An Advisory Council dedicated to post-acute rehabilitation care should be formed within CMS and given a broad mandate to provide recommendations and ongoing advice to the Administrator, the Innovation Center, and others on issues relating to testing and implementing Medicare policies for post-acute rehabilitation services. The Advisory Council would have authority to review and comment on any CMS regulatory changes, innovation models, or other policies in development impacting post-acute care providers.

routine calls and listening sessions with interested stakeholders to obtain feedback on models at each of these stages of development and implementation. In general, more structured and regular communication between the Innovation Center and the providers its programs impact would foster a higher level of understanding of various innovation efforts, and ultimately the “buy in” and success these initiatives achieve.

In summary, our comments focus on implementing the continuing care hospital (CCH) as a new model that meets CMS’ guiding principles, maintaining medically necessary care that ensures quality, improving Medicare Advantage access, establishment of a Post-Acute Care Advisory Council to help guide the agency’s policymaking, and improving CMS communication with stakeholders. AMRPA members are committed to bigpicture reforms that redefine the value proposition of medical rehabilitation and truly place patients back at the center of their care. We are working on some very exciting initiatives with the private sector and welcome the opportunity to discuss them with CMS when appropriate.

AMRPA appreciates the opportunity to provide comments and we thank the agency for its interest and willingness to engage stakeholders as it develops a new policy direction for the CMS Innovation Center. If you have any questions do not hesitate to reach out to Carolyn Zollar, Executive Vice President for Policy Development and Government Relations of AMRPA (202-2231920, czollar@amrpa.org) or Martie Kendrick, AMRPA’s Washington Counsel (202-887-4215, mkendrick@akingump.com).

Sincerely,

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

B. Increasing CMS Transparency with Stakeholders In response to previous RFIs, AMRPA has called on CMS to establish periodic Open Door Forum (ODF) conference calls on inpatient rehabilitation as a way to provide important updates on relevant CMS activities and to solicit stakeholder feedback. We believe that monthly ODF calls—such as those that exist for other Medicare providers, including other post-acute care providers— would facilitate greater transparency and alignment in medical rehabilitation policy.

While ODFs are of course not a function of the Innovation Center, we believe that similar transparency would benefit it as well. First, ODFs should discuss current models, those under development, and those under consideration that are relevant to particular providers. Likewise, the Innovation Center should have more 41

2018 AMRPA BOARD OF DIRECTORS Board Chair Rich Kathrins, PhD, CEO Bacharach Institute for Rehabilitation Board Vice Chair Bob Krug, MD, Medical Director, PM&R Service Line Mount Sinai Rehabilitation Hospital Treasurer David Storto, President Partners Continuing Care and Spaulding Rehabilitation Network Secretary Anthony Cuzzola, Vice President JFK Johnson Rehabilitation Institute Immediate Past Chair Bruce M. Gans, MD, Executive Vice President and Chief Medical Officer Kessler Institute for Rehabilitation Member-At-Large Kathy Yosko, PhD, President Marianjoy Rehabilitation Hospital Member-At-Large Mark Tarr, President and CEO Encompass Health Directors Doug Baer, President and CEO Brooks Rehabilitation Hospital Phil Loverso, PhD, President and CEO Casa Colina Hospital and Centers for Healthcare

Suzanne Snyder Kauserud, Vice President Carolinas Rehabilitation Mary Beth Walsh, MD, CEO Burke Rehabilitation Hospital, Inc. Russ Bailey, COO Kindred Hospital Rehabilitation Services Gregg Stanley, VP of Rehabilitation Services HCA Bill Restum, PhD, President and CEO Rehabilitation Institute of Michigan Carol Sim, President and CEO Siskin Hospital/Physical Rehabilitation John Kristel, President and CEO Good Shepherd Rehabilitation Network Christopher Lee, Vice President of Rehabilitation Madonna Rehabilitation Hospital Kent Riddle, CEO Mary Free Bed Rehabilitation Hospital Karl Sandin, MD , MPH, Medical Director and Assistant Professor Immanuel Rehabilitation Institute Department of Surgery, Creighton University School of Medicine Alberto Esquenazi, MD, Chair of the Department of PM&R MossRehab

Chip Eisenman, CEO Sunnyview Rehabilitation Hospital

Anne Marie McDonough, Senior Director of Rehabilitation Medicine North Shore/Staten Island University Hospital

John Rockwood, President National Rehabilitation Hospital

Michael Long, Division President, Rehabilitation Vibra Healthcare

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