March 2018 • Vol. 21, No. 3
PROTECTING THE VALUE OF CARE IN AN ERA OF DISRUPTION
Volume 21, Number 3
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
New DOJ Memos Could Help IRFs with Medicare Appeals........................... 8
Peter Thomas, JD Counsel to the AMRPA Consumer and Clinical Affairs Committee, Principal, Powers Pyles Sutter & Verville, PC
Defining the Roles of PPS Coordinators, Coders, and Clinical Documentation Improvement Specialists.......................................... 11
Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-Advanced Outcomes Design Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA Jonathan M. Gold, JD Regulatory and Government Relations Counsel, AMRPA Mimi Zhang Senior Policy and Research Analyst, AMRPA Lovelyn Robinson Editorial and Research Assistant, AMRPA
AMRPA Legislative Update................................................................................. 4
Budget Process Basics and Potential Impact on Medical Rehabilitation Providers .................................................................... 13 More Details Emerge on BPCI Advanced ...................................................... 15 CMS Withdraws Recently Issued IRF Guidance Booklet After AMRPA Inquiries; Other New Guidance Remains ................................ 18 Medicare Part B Payment Increases Will Offset 340B Drug Reimbursement Cuts, Avalere Says ............................................. 20 GAO: CMS Needs to Improve the Efficiency of the Home and Community-based Services Program .......................................... 21 Brain-Scan Guided Emergency Stroke Treatment Led to Better Outcomes, NIH Finds................................................................ 23 Wearing Biosensors Does Not Significantly Improve Patient Outcomes, Study Finds........................................................................ 24
AMRPA Magazine, Volume 21, Number 3. 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.
Study Finds Aspiration Effective in Stroke Interventions............................... 25 MACPAC Issues Data Book on Dual-Eligible Beneficiaries........................... 27 AMRPA Federal Election Center...................................................................... 30
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 Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content Š2017 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 March 2018
LETTER FROM THE CHAIR
Letter from the Chair Protecting the Value of Care in an Era of Disruption Richard Kathrins, PhD, CEO, Bacharach Institute for Rehabilitation RKathrins@bacharach.org
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ortune magazine recently ran an article about Amazon, Berkshire Hathaway and J.P. Morgan Chase forming a not-for-profit health care venture to lower health care costs for their U.S. employees. The article went on to quote Jamie Dimon, chair and CEO of J.P. Morgan Chase as saying, “…our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans (as cited in “Amazon, Berkshire Hathaway,” Jan. 30, 2018, para 9).” In an effort to disrupt the current health care system, how could we not applaud a group for trying to bring together, “experts, a beginner’s mind, and a long-term orientation,” as suggested by Jeff Bezos (as cited in “Amazon, Berkshire Hathaway,” Jan. 30, 2018, para 7). According to Sanger-Katz and Abelson (2018), the devil will be in the details and it is worth it for all of us to carefully monitor this new initiative to see if this collaborative group can improve health care where other large corporations such as Google and Microsoft have struggled. The authors implied that “disrupting” health care with lower value and cost may not work as consumers will continue to demand high quality. Value of health care is defined as a function of outcome per unit of cost. We need to ensure that any proposed disruption in the delivery of care maintains a set of principles that protects the value of care. The value of care has long been tested in health care delivery markets. Jha (2017) noted that paying more for good performance and value-based purchasing (of health care) have had discouraging results. Cost reduction strategies alone will not drive improvement
in health care. Some basic principles need to be developed and serve as the basis for any innovative model that strives to improve the value of the current health care system to its members. We could argue that these principles should include the ability to improve care for the individual, improve the health of the population and reduce the cost for a set of outcomes. We should be particularly concerned as rehabilitation providers care for the most vulnerable and we need to ensure that access is not restricted for the sake of reducing cost in the short term. Consumers of health care will continue to demand high-quality services. We could ask Alexa if these new entrants will be successful, but acknowledging and meeting basic principles will be no small undertaking for a group that has no prior experience in the health care delivery marketplace. Yet the efforts of such a formidable group deserves our attention. References Amazon, Berkshire Hathaway and J.P. Morgan are Forming a Non-Profit Health Care Venture (2018, Jan 30). Retrieved from http://fortune. com/2018/01/30/amazon-berkshire-hathaway-jpmorgan-nonprofithealth care/ Sanger-Katz, M. and Abelson, R. (2018, Jan 30). Can Amazon and Friends Handle Health Care? There’s Reason for Doubt. Retrieved from https:// www.nytimes.com/2018/01/30/upshot/can-amazon-and-friends-handlehealth-care-theres-reason-for-doubt.html Jah, A.K. (2017, March 21). Value-based purchasing: time for reboot or time to move on? JAMA, 317 (11), 1107-8.
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AMRPA LEGISLATIVE UPDATE
By Martha M. Kendrick, Esquire, Partner, Akin Gump Strauss Hauer & Feld LLP
Bipartisan Budget Breakthrough in Congress
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n Thursday, January 18, the House passed by a vote of 230-197 a continuing resolution (CR) that would extend government funding through February 16 and reauthorize the Children’s Health Insurance Program (CHIP) for six years, delay the Cadillac tax for two years, delay the medical device tax for two years, and delay the health insurance tax by one year. Six Democrats voted for the measure, while 11 Republicans voted against it. Late in the evening on January 19, the government entered a
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On Sunday, January 21, the Senate Majority Leader McConnell (R-KY) offered a three-week CR to fund the government through February 8, and a commitment in writing to immediately consider immigration legislation on the floor if a deal on DACA was not reached by
Negotiations continued into February with little expectation that Congress would come to agreements on the spending levels for fiscal year (FY) 2019, a major hold up and reason behind multiple CRs, or immigration reform. On the week the CR was to expire, House Republicans on February 5 released a FY 2018 CR to fund most federal agencies through March 23, 2018. The CR also included appropriations to fund the Department of Defense through September 30, 2018, Medicare payment extenders and other health care provisions.
Congress finally comes to bipartisan, bicameral agreement on a budget deal that addresses budget caps, the looming debt ceiling, and several health care measures, including permanent repeal of the therapy caps and ending the Affordable Care Act’s Independent Payment Advisory Board (IPAB). The CHRONIC Care Act, a Senate-passed bill that aims to reform how Medicare treats patients with multiple chronic diseases, is also included in the budget deal. Former pharmaceutical executive and Bush administration official, Alex Azar, was sworn into office as the new Secretary of Health and Human Services (HHS) on January 29, 2018. The FY 2019 budget process is expected to begin on February 12 with the release of the President’s Budget Request.
partial shutdown after the Senate failed to advance the House-passed CR before midnight. The cloture vote failed at 5049, short of the 60 votes needed to pass the motion. Senate Republicans needed support from several of their Democratic colleagues in order pass a bill that would have temporarily kept the government open. Senate Democrats pushed back on the House-passed CR because it did not include immigration reform. Lawmakers
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had been trying to negotiate a bipartisan policy with President Trump for several few weeks, but remained at an impasse. At midnight on January 19, the federal government officially shut down with no clear breakthrough.
February 8. House Leadership confirmed they would support such a measure. On Monday, January 22, the Senate Minority Leader Schumer (D-NY) confirmed enough Senators from his caucus would support the CR with the immigration commitment. The Senate voted 81-18 that finalized passage of a three-week CR (along with CHIP reauthorization and ACA taxes) and sent the spending measure to the House, where it passed by a vote of 266-150.
Of significant interest to AMRPA members, the House-passed CR included – and the Senate retained – a permanent repeal of the therapy caps and a five-year extension of the home health rural add-on. The therapy caps repeal is retroactive to December 21, 2017, and lowers the threshold for targeted manual medical review process from $3,700 to $3,000. Claims submitted over the current $2,010 threshold will require an appropriate modifier to be
AMRPA Magazine March 2018
Medicare Extenders in Bipartisan Budget Act of 2018 (P.L. 115-123) Provision Therapy Caps
Medicare-Dependent Hospital (MDH) Program
Low-Volume Hospital (LVH) Payment Adjustment
Summary • Permanently repeals the therapy caps (retroactive to December 31, 2017). • Lowers threshold for targeted manual medical review process from $3,700 to $3,000.
• Extends the MDH program for five years until October 1, 2022 (retroactive to October 1, 2017). • Requires GAO study on the MDH program.
• Extends the MDH program for five years until October 1, 2022 (retroactive to October 1, 2017). • Bases payment adjustments on total discharges beginning October 1, 2018.
Ambulance Add-on Payments
• Extends the ambulance add-on payments for five years through December 31, 2022 (retroactive to January 1, 2018). • Includes cost reporting requirements for ambulance services.
Home Health Rural Add-on
• Extends the home health add-on for five years (retroactive to January 1, 2018). • Includes a new payment methodology to target the add-on to areas with a population density of 6 or fewer individuals per square mile (effective for visits and episodes ending in 2019 or later). • Extends the GPCI floor for two years until January 1, 2020 (retroactive to January 1, 2018).
Work Geographic Practice Cost Index (GPCI) Floor
Special Needs Plans (SNPs)
• Permanently reauthorizes Medicare Advantage SNPs. • Makes changes to D-SNPs and C-SNPs to improve care management.
© 2018 Akin Gump Strauss Hauer & Feld LLP
included 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). This was a bipartisan, bicameral, and tri-health care committee supported deal that is considered a significant policy victory for stakeholders and patients affected by therapy services. Although the home health rural add-on was extended for five years, it is now modified and targeted based on population density, and essentially a targeted phase down over five years. Retroactive to December 31, 2017, the add-on is extended at the current 3 percent for 2018. In 2019, the home health add-on would increase from 3 to 4 percent for counties with a population density of 6 or fewer individuals per square mile; then drop to 3 percent in 2020, 2 percent in 2021, and 1 percent in 2022. Counties in the highest quartile based on the number of Medicare home health
episodes furnished per 100 individuals, the home health add-on will be reduced to 1.5 percent in 2019 and .5 percent in 2020. In 2019 the home health add-on would increase from 3 to 4 percent for counties with a population density of 6 or fewer individuals per square mile; then drop to 3 percent in 2020, 2 percent in 2021, and 1 percent in 2022. Other rural counties would see the add-on payments at 3 percent in 2019, reduced to 2 percent in 2020, reduced to 1 percent in 2021. The CR also requires the secretary to reform the current home health payment system, beginning January 1, 2020, with the implementation of a budget neutral 30-day episode for payment. The CR provides “face to face” documentation relief by giving the secretary the authority to utilize the medical records of home health providers, in addition to the medical records of physicians, when determining a patient is eligible for home health services. Additionally, the bill requires a 1.5 percent FY 2020 market basket update for home
health agencies, which is estimated to be a $3.5 billion reduction in Medicare payments. The package also incorporates the Senatepassed CHRONIC Care Act (S. 870), The Part B Improvement Act, and the provisions of other health care bills reported out of the House Energy and Commerce Committee and the House Ways and Means Committee. The CHRONIC Care Act provisions of interest to AMRPA include the expansion of telehealth benefits in Medicare Advantage plans and elimination of the geographic restrictions for telestroke consultation services. The health care portion of the bill is fully offset; however, Democrats objected to certain pay-for provisions, including cuts in the Prevention and Health Fund established under the Affordable Care Act (ACA). The House voted 245-182 to pass the stopgap spending measure on February 6, with 17 Democrats voting in favor and eight Republicans voting no. 5
Given Democratic opposition to the House bill, when the House-passed bill reached the Senate, as expected, the package was amended. In a somewhat surprising show of bipartisanship, Senate Leaders McConnell and Schumer announced a bicameral, bipartisan agreement that not only funds the government through March 23, but includes a breakthrough in addressing the levels of the budget caps that had been holding up negotiations for months. The Senate agreement maintains several of the House-passed Medicare extender policies, including repeal of the therapy caps and the rural home health add-on extension. The CHRONIC Care Act provisions are also included in the Senate version. The new Senate budget agreement also adds another four years to the Children’s Health Insurance Program (CHIP) that carries the program reauthorization through FY 2027. Similar to the House, the Senate package includes several offset provisions in order to pay-for the policies, including a two-year extension of the two-percent Medicare sequestration cuts through FY 2027, a reduction resulting in 2.4 percent payment update for the skilled nursing facility market basket, rescinding all available funds currently held in the Medicare and Medicaid Improvement Funds, eliminating the Medicaid Disproportionate Share Hospital (DSH) reductions scheduled for FY 2018 and FY 2019 under current law, and accelerating the closure of the Medicare Part D “donut hole” to 2019 instead of 2020. Unfortunately, the therapy cap offset reflects a 15 percent reduction in payments for outpatient therapy services furnished entirely or in part by a physical or occupational therapy assistant. The federal government experienced a brief shutdown in the early morning hours of February 9 due to Sen. Rand Paul’s (RKY) objection to the fast-track procedural move to vote on such a substantial budget package without allowing for a vote on an amendment to maintain the strict spending caps. The Senate eventually filed cloture and passed the bill around 2 a.m. on February 9, with a final vote of 71-28, followed by a House vote of 240-186 on the bill at 5:45 AM. The President promptly signed the bill into law. HHS Secretary Officially Confirmed by the Senate On January 24, 2018, the Senate voted 6
55-43 to confirm Alex Azar to be the next Secretary for the U.S. Department of Health and Human Services (HHS), succeeding former Republican Congressman Tom Price, who came under fire last fall for his use of private air transportation. Sen. Rand Paul (R-KY), who criticized Azar for not supporting drug importation, voted no. Secretary Azar is a former pharmaceutical executive, and spent several years as a deputy secretary at HHS during the George W. Bush administration. During his confirmation hearings, he outlined several priorities, which include addressing the cost of prescription drugs and the opioid crisis, expanding access to association health plans and short-term health insurance, and continuing the shift to a value-based payment system. In his first speech after being sworn in, Secretary Azar called for more action on the opioid crisis and pledged to make lowering drug prices a priority. His first major action as HHS Secretary was approval of Indiana’s Medicaid waiver allowing work requirements for recipients. Less than two days later after being sworn in, Centers for Disease Control and Prevention (CDC) Director Brenda Fitzgerald resigned after it was reported she bought shares in a tobacco company while leading the agency. Fitzgerald had already come under scrutiny for not divesting older holdings quickly enough. President’s FY 2019 Budget Released on February 12 After a slight delay that the Trump Administration blamed on the recent government shutdown, the FY 2019 budget process was set to begin on February 12 with the release of the President’s Budget Request. Ways and Means Committee Chairman Kevin Brady (R-TX) announced that the Committee will hold a hearing on President Trump’s FY 2019 Budget Proposals for HHS on February 14. House Energy and Commerce Committee Chairman Greg Walden (R-OR) announced a series of hearings related to the request, including a Subcommittee hearing on the HHS budget on February 15. Office of Management Budget Director (OMB) Mick Mulvaney is confirmed to testify before the Senate Budget Committee on February 15. There are few details at the moment on what the request may contain, but the Administration’s budget may propose significant cuts to HHS and its sub-agencies.
Debate over Veteran’s Choice Program Expected to Resume The Senate Veterans’ Affairs Committee is hoping to restart stalled negotiations over reforms to the Veterans’ Choice Program, after White House officials issued guidance to the Committee on eligibility rules and costs. Chairman Johnny Isakson (R-GA) and Ranking Member Jon Tester (D-MT) are reviewing the guidance and working to reach a compromise. White House officials appear to favor a bill more consistent with legislation sponsored by Sen. Jerry Moran (R-KS), which would expand veterans’ access to community-based care. Advisory Panel on Hospital Outpatient Payment Nominations CMS is requesting nominations to the Advisory Panel on Hospital Outpatient Payment. Nominations will be accepted on a rolling basis. The panel advises CMS on the clinical integrity of the Ambulatory Payment Classification (APC) groups and relative payment weights that are components of the Medicare Hospital Outpatient Prospective Payment System (OPPS), and the appropriate supervision level for hospital outpatient therapeutic services. *** We need your presence and voice! We are looking forward to having AMRPA members come to Washington, DC, to participate in AMRPA’s upcoming March 12-13 Spring Conference and Congressional Fly-In. If you have not registered yet, please do! Members of Congress need to hear your voice about several important policy issues that affect rehabilitation hospitals, such as value-based purchasing, implementation of the IMPACT Act, and issues related to managed care. While we dodged large bullets in the Congressional Budget Deal, the massive budget negotiations negatively hit several post-acute sectors. Congress will again have pen in hand for the next Appropriations funding deadline of March 23. AMRPA members must be prepared to defend patients’ access to critical, rehabilitative care! Please do not hesitate to reach out if you have any questions about the Fly-in and/or AMRPA’s legislative priorities.
AMRPA Magazine March 2018
March 11-13, 2018 Embassy Row Hotel • Washington, DC Registration is Open Visit us at www.amrpa.org for the agenda, CE credit information, and to register today. Congressional Fly-In – earn credit while hearing updates directly from federal agency officials and policy influencers in the morning, and then join us prepared for Hill visits scheduled by AMRPA in the afternoon. (March 12-13) Medical Directors Symposium - provide your physician leadership with the knowledge and networking opportunities they need to stay informed on the latest issues in the field. (March 11) Rehabilitation Administrators Workshop – an opportunity for your operational leadership to cover or revisit the basics of regulations for inpatient medical rehabilitation hospitals and units. (March 11) Know someone who is a nonmember? Nonmembers who register for the conference receive a 6 month free trial membership for their organization! Questions? Contact Samantha Schwarz, AMRPA Member Services Coordinator, at sschwarz@amrpa.org or by calling 202-207-1132.
#AMRPA 7
NEW DOJ MEMOS COULD HELP IRFS WITH MEDICARE APPEALS
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he U.S. Department of Justice (DOJ) recently issued two memorandums that could significantly reduce the number of future Medicare denials in inpatient rehabilitation hospitals and units (IRFs) and provide IRFs with a powerful argument to overturn existing denials. Although the memos do not directly address IRFs, they do state a federal policy that guidance documents may not create binding rules. The Medicare Benefits Policy Manual (MBPM) is one such guidance document, and it contains numerous requirements that are not stated in the regulations governing IRF coverage. These MBPM provisions may now be unenforceable.
A Short History of Rulemaking The authority of federal agencies, such as the Centers for Medicare and Medicaid Services (CMS), to issue binding rules is constrained by the U.S. Constitution and federal statutes. It is common knowledge that the Constitution vests lawmaking authority with Congress, and the executive branch is tasked with carrying out those laws. More than 70 years ago, Congress enacted the Administrative Procedure Act (APA), which created the process for executive agencies to issue rules that are binding on the public. In effect, Congress used its lawmaking authority to permit agencies to issue “laws” in the form of regulations. For a rule to have the force and effect of law, the APA generally requires an agency to go through the “notice and comment” process. Members of the IRF community will be familiar with the annual IRF Prospective Payment Rule that is published in the Federal Register, which goes through notice and comment. The IRF coverage regulation at 42 C.F.R. § 412.622 was promulgated through the APA notice and comment process in 2010. That regulation is binding, and IRFs must comply with it to be paid by Medicare. Of course, any rule must be consistent with federal statutes. 8
Agencies also issue “guidance” to explain federal statutes and regulations. The MBPM is one such guidance document. Because guidance is not issued through the rigorous APA notice and comment process, it has long been established that guidance cannot create new binding rules. Guidance can only explain existing rules.
or regulation. That a party fails to comply with agency guidance expanding upon statutory or regulatory requirements does not mean that the party violated those underlying legal requirements; agency guidance documents cannot create any additional legal obligations.
The DOJ Memos Limit the Authority of “Guidance” In two recent memos, DOJ restated these principles and emphasized that DOJ will not enforce agency guidance that creates obligations that are not stated in properly promulgated regulations. In November, Attorney General Sessions issued an internal memorandum (the Sessions Memo) stating that DOJ must “use, in most cases, notice-andcomment rulemaking when purporting to create rights or obligations binding on members of the public or the agency.” The Attorney General emphasized that “guidance may not be used as a substitute for rulemaking and may not be used to impose new requirements on entities outside the Executive Branch.” In addition, it stated that, “[g]uidance documents should not use mandatory language such as ‘shall,’ ‘must, ‘required,’ or ‘requirement’ to direct parties outside the federal government to take or refrain from taking action, except when restating—with citations to statutes, regulations, or binding judicial precedent—clear mandates contained in a statute or regulation.”
The two memos are not, technically, binding on CMS. The memos state DOJ policies for internal DOJ guidance and for how DOJ will treat other agencies’ guidance in enforcement actions. The memos do not directly constrain CMS and its contractors, such as Medicare administrative contractors (MACs) and
ABOUT THE AUTHORS
Peter W. Thomas Counsel to the AMRPA Denials Management Committee and the Consumer and Clinical Affairs Committee
The Sessions Memo applied to guidance documents created by DOJ. In January, Associate Attorney General Rachel Brand issued a second memo applying the principles of the Sessions Memo to DOJ enforcement actions: [T]he Department should not treat a party’s noncompliance with an agency guidance document as presumptively or conclusively establishing that the party violated the applicable statute
Ronald S. Connelly, Principal, The Powers Firm AMRPA Magazine March 2018
recovery audit contractors (RACs), when auditing Medicare claims. Nonetheless, CMS should act consistently with the memos because the Attorney General is the top lawyer in the federal government. Moreover, if an IRF appeals one or more Medicare denials to court, DOJ would apply the principles of the two memos.
Many MBPM Provisions May Be Unenforceable Under the DOJ Memos The policies of the two DOJ memos could have profound impacts on IRF coverage. IRFs are subject to extensive coverage requirements. The regulations governing IRF coverage are more detailed than for most Medicare-covered services. But, the MBPM goes far beyond even the regulations. As a result of these memos, many MBPM “requirements” are now vulnerable and may not be enforceable. For instance, the IRF regulation requires a preadmission screening (PAS), which must be conducted by a licensed clinician within 48 hours of admission. According to the regulation, the PAS
“includes a detailed and comprehensive review of each patient’s condition and medical history,” “serves as the basis for the initial determination of whether or not the patient meets the requirements” for admission, “is used to inform a rehabilitation physician who reviews and documents his or her concurrence with the findings and results of the preadmission screening,” and is retained in the patient’s medical record. The MBPM creates many additional requirements that are not present in the regulation: The preadmission screening documentation must indicate the patient’s prior level of function (prior to the event or condition that led to the patient’s need for intensive rehabilitation therapy), expected level of improvement, and the expected length of time necessary to achieve that level of improvement. It must also include an evaluation of the patient’s risk for clinical complications, the conditions that caused the
need for rehabilitation, the treatments needed (i.e., physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), expected frequency and duration of treatment in the IRF, anticipated discharge destination, any anticipated post-discharge treatments, and other information relevant to the care needs of the patient. The regulation is silent about all of the highlighted sections of this MBPM passage. Arguably, if any of these items are missing from the PAS, a MAC, RAC, or other contractor should not automatically deny the claim. Last year, a federal district court in North Carolina, in Cumberland County Hospital System v. Price, overturned several IRF denials in favor of the IRF that were based on the above MBPM paragraph. The court held that the “list of criteria in the MBPM does not merely clarify or interpret the requirements in the 9
regulation, but creates a new standard by specifying particular items of information not provided for in the regulation.” Because the MBPM was not issued via APA notice and comment procedures, the PAS criteria could not be imposed as absolute requirements. The DOJ memos do not mention the Cumberland County decision, but the memos bolster the persuasiveness of that decision.
the IOPC must be “developed by a rehabilitation physician . . . with input from the interdisciplinary team within four days of the patient’s admission to the IRF” and retained in the medical record. The MBPM adds that the IOPC “must detail the patient’s medical prognosis and the anticipated interventions, functional outcomes, and discharge destination.” It also “must include the expected intensity (meaning number of hours per day), frequency (meaning number of days per week), and duration (meaning the total number of days during the IRF stay).” Note that these are all phrased with the mandatory “must,” which the Attorney General expressly forbids in guidance documents.
three hours per day in therapy for five days per week. The clear emphasis is on the effort of the patient, not the therapy resources of the IRF. Under the reasoning of the DOJ memos and the Cumberland County case, CMS should not be able to impose the MBPM-based limitations on group and concurrent therapy. IRFs should keep in mind that the DOJ memos do not expressly invalidate the above MBPM provisions. IRFs should expect, likely in the near term, that Medicare contractors will continue to deny coverage for IRF stays that do not meet all MBPM standards. CMS may issue statements clarifying whether or not it views the MBPM as binding on IRFs (and Medicare audit contractors), and AMRPA may decide to press them to do so. It is possible that CMS could also initiate notice and comment rulemaking to add some or all of these requirements to the regulation in future rulemaking.
Other PAS MBPM requirements are also vulnerable, including the mandate that “the rehabilitation physician must document that he or she has reviewed and concurs with the findings and results of the preadmission screening prior to the IRF admission.” The regulation states that the PAS must serve as the The MBPM also adds to the substantive basis for the decision to admit the IRF coverage requirements in several patient and that the physician must document concurrence with the PAS, but the regulation is silent about when the physician must document concurrence. While IRFs would incur less This is a significant developThis is a significant development risk if they continue to comply with this MBPM provision, ment for IRFs and all Medifor IRFs and all Medicare providers IRFs can now argue that care providers in leveling the in leveling the playing field of contractors should not deny playing field of Medicare aua claim simply because the dits and appeals. IRFs should Medicare audits and appeals. physician documents his or closely examine all Medicare her concurrence with the PAS denials to assess whether the after the patient is admitted. contractor has denied coverrespects. One important MBPM section age based solely on MBPM standards limits the use of group and concurrent The Post-Admission Physician Evaluation or other guidance documents that are therapy: (PAPE) fairs no better under the not clearly expressed in Medicare regureasoning of the DOJ memos. The lations. These denials should clearly be The standard of care for IRF regulation requires that the rehabilitation appealed in light of these developments. patients is individualized (i.e., onephysician completes the PAPE within IRFs should cite the Cumberland County on-one) therapy. Group therapies 24 hours of the patient’s admission to decision and the DOJ memos to argue serve as an adjunct to individual the IRF, and the PAPE must document that their claims should not be denied therapies. In those instances in “the patient’s status on admission to based solely on MBPM or other guidwhich group therapy better meets the IRF,” include “a comparison with the ance that is not present in the Medicare the patient’s needs on a limited information noted in the preadmission statute or IRF regulations. basis, the situation/rationale that screening documentation,” and serve justifies group therapy should be “as the basis for the development of The opinions expressed in this article specified in the patient’s medical the overall individualized plan of care.” should not be construed as legal advice. record at the IRF. The MBPM adds the requirements that IRFs should seek the counsel of an the PAPE “must include a documented attorney when evaluating compliance The concept of “individualized” therapy history and physical exam, as well as a with Medicare coverage rules. is absent from the regulation. Indeed, review of the patient’s prior and current the regulation defines “an intensive medical and functional conditions and rehabilitation therapy program” based comorbidities.” on the amount of time that the patient spends in therapy, not on the number of The MBPM imposes many requirements therapists present. The regulation makes for the Individualized Overall Plan of clear that an intensive therapy program is Care (IOPC) that are not present in the generally one where the patient spends regulation. According to the regulation,
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AMRPA Magazine March 2018
DEFINING THE ROLES OF PPS COORDINATORS, CODERS, AND CLINICAL DOCUMENTATION IMPROVEMENT SPECIALISTS By Lisa Werner, MBA, MS, CCC-SLP
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ver the years, I have noticed more and more clinical documentation improvement (CDI) specialists working in inpatient rehabilitation centers. When new roles are introduced into the rehabilitation ecosystem, questions may arise as to which positions are responsible for what Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) coding tasks. In my professional opinion, there are distinct differences between the roles of PPS coordinators, coders, and CDI specialists. I have witnessed firsthand the successes that result from properly utilizing the expertise and knowledge inherent to each of these positions. Working together as a team, staff members in these three roles should be able to craft thorough IRF-PAI’s that reflect the true burdens of care for all patients admitted to rehabilitation.
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Coders follow AHIMA guidelines and issue queries as needed.
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Queries are shared with the CDI specialist(s) for informational purposes only.
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Follows up with physicians to verify that queries receive responses.
The coder is specifically responsible for populating the following fields on the IRF-PAI:
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Requires access to both eRehabData and the coding software.
-- Impairment group code (IGC) – item 21
PPS Coordinators:
-- Date of onset – item 23
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Must also review and code the history and physical (H&P), code progress notes once per week, and code at discharge.
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Reviews coding warnings on the Medical tab in eRehabData and discuss them with CDI specialists and coders to determine the most accurate IGC’s and etiologic diagnoses.
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Completes items “24A – Arthritis conditions,” “25A – Height on admission,” and “26A – Weight on admission.”
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Enters/loads and compares items on the functional independence measures (FIM), cognition and function tabs to the documentation in the record. This includes all FIM scores and quality indicator items.
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Validates data from the pre-admission screening (PAS) tool uploader and enters data in items “750 – History of falls,” and “J2000 – Prior surgery.”
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Completes items in IRF-PAI sections “J – Health conditions,” “K – Swallowing/Nutrition Status,” and “O – Special Treatments, Procedures, and Programs,” on the dx/hx/stats tab at both admission and discharge.
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Enters or uploads data from the electronic medical record and validates items on the skin tab at both admission and discharge.
•
Enters or uploads therapy minutes at
-- Comorbidities and coexisting conditions – items I0900, I2900, I7900 -- Diagnosis for interruption or death – item 46 -- Complications during rehabilitation – item 47 -- Completes the eRD tab based on the information in the H&P, progress notes and discharge summary -- Signs the IRF-PAI when these items are completed at admission and discharge -- Assigns codes for the UB-92
•
Reviews CMGs in eRehabData.
•
Assists coders with selecting IGC’s and etiologic diagnoses through discussions with physicians.
•
Reviews the following documentation: the H&P, consultations, progress notes and discharge summaries for missed diagnoses.
Coders: Primarily responsible for determining ICD-10 codes for patient stays.
Completes the IRF-PAI (including the ID Admin tab).
-- Comorbidities – item 24
CDI Specialists:
•
•
-- Etiologic diagnosis – item 22
If your rehabilitation unit or hospital is considering adding CDI specialists, I have included a list of potential tasks and responsibilities specific to each of these positions. The goal is to have all three roles specifically defined so that their tasks and responsibilities help to complement each other’s work rather than duplicate it. Specific responsibilities and tasks for coders, CDI specialists and PPS coordinators
coding, clarification of onset status, severity of illnesses and quality items such as pressure ulcers.
•
Opens queries for comorbidity
11
discharge and validates them. •
Completes the discharge tab.
•
Reviews the entire IRF-PAI for accuracy.
•
Addresses all coding and FIM scoring warnings in eRehabData.
•
Signs the IRF-PAI upon completion of both the admission assessment and the discharge assessment.
•
Oversees therapy and nursing education for FIM and function quality measures.
•
Works with staff one-to-one and in small groups on FIM scoring and quality indicator coding proficiency.
While these suggestions can help to guide you in parsing tasks fairly,
efficiently and according to each staff member’s strengths, whether or not these specific responsibilities will work in your rehabilitation unit is ultimately up to you. In the most general terms, the PPS coordinator should possess expert knowledge of the IRF-PAI and take on the responsibility of making sure that the final documents are reviewed thoroughly in order to verify their valid, accurate representations of each treated patient. However, all three positions should receive ample training in the IRF-PAI completion process. Whether someone is an expert in need of a refresher, or a new hire in need of comprehensive training, they can all benefit from the following: reading and digesting the IRF-PAI Training Manual, attending workshops or classes, participating in free eRehabData
Clinical Training Webinars, networking with other PPS coordinators, signing up for AMRPA alerts and Off The Record updates, and paying attention to CMS updates (it is critical to stay up-to-date on new information). Ultimately, in working together as a team, the PPS coordinator, the CDI specialist, and the coders should be able to efficiently and accurately create IRFPAI’s that convey the correct burdens of care for each patient. This will virtually guarantee that you receive accurate reimbursement for the highest possible quality of care you are able to provide.
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12
AMRPA Magazine March 2018
BUDGET PROCESS BASICS AND POTENTIAL IMPACT ON MEDICAL REHABILITATION PROVIDERS By Carolyn C. Zollar, MA, JD, Executive Vice President of Government Relations and Policy Development, AMRPA
T
he formal federal budget process is an annual event that establishes levels of spending for the coming federal fiscal year. This year, the president was expected to introduce his fiscal year 2019 budget proposal to Congress on February 12 after our publication deadline. The next step will be for the Budget Committee in each chamber of Congress to formally receive the proposal and then hold hearings. Generally, the two committees draft a budget proposal of their own, which is then embodied in a budget resolution. The House and Senate Budget Committees generally mark up and report their resolutions in March. The budget law requires the House and Senate to agree on a budget resolution by April 15, a date usually honored in the breach. The budget resolution allows Congress to put into place revenue and spending proposals within the framework of its own budget plan. Although the resolution is binding on both houses, the president is not bound by it. As with any executive branch proposal, Congress then acts on it…or not. The budget process (in theory) is as follows: Subsequent to receiving the president’s budget, as noted each Budget Committee promptly holds hearings. In March, the committees hold markups using the information from the hearings. After the markups are concluded, the committees report to their respective chambers a concurrent resolution on the budget. In April, Congress adopts a joint budget
resolution. includes:
This
resolution,
usually,
1. Budget totals – This includes the budget aggregate, total revenues, total new budget authority, total outlays, and total revenues and outlays by budget function and committee allocations. 2. The amounts to be spent on major functions or purposes served by federal government programs. For example, transportation, defense and income supports are three different budget functions. Medicare is function 570. 3. Reconciliation instructions – These are orders to various congressional committees to find ways to reduce the cost of entitlement programs, to raise revenues by a certain amount or increase or decrease the public debt. The reconciliation instructions are of specific interest to all medical rehabilitation providers because, in order to meet the instructions, the committees of jurisdiction in which we are interested (the House Ways and Means Committee, House Energy and Commerce Committee and Senate Finance Committee) may make reductions in Medicare. 4. Congressional budget enforcement mechanisms – This process includes the concept of pay-as-you-go and reserve funds. 5. Statements of budget policy. After each chamber has passed its version of the resolution, each one appoints
Highlights: •
•
Annual FY 2019 budget process about to begin when FY 2018 is not concluded. Traditional budget process and terms good to know for upcoming deliberation.
members to a conference committee to resolve the differences. Once there is an agreement, the action then shifts to the appropriation and authorizing committees. Appropriations: Each house of Congress has an appropriations committee, which has 13 subcommittees. Each of the 13 subcommittees oversees spending for a set of departments or agencies. After the budget committee sets ceilings for spending on the various government functions, each appropriations subcommittee is given an allocation. This is the total dollar amount to be divided up among all the programs under its authority. Each subcommittee then recommends specific appropriations for specific programs. Each subcommittee's recommendations become one of 13 appropriation bills, which are then reported to the full Appropriations Committee. After the full Appropriations Committee approves the bill, it goes to the floor in each house. After approval by the Senate and House, and after working out the differences between House and Senate bills in conference, the bills go to the president for his signature. 13
If there are no appropriations bills for all or some of the departments by the end of the federal fiscal year (September 30), a continuing resolution (CR) or a series them are enacted. For the current fiscal year, FY 2018, Congress has passed a series of continuing resolutions and yet failed to pass one of them on time, leading to a short government shutdown in midJanuary.
one of those subjects, no subsequent reconciliation bill can affect either revenues or spending because the first bill already addressed them. Using the Senate reconciliation process has certain advantages. Only a simple majority vote is needed to pass, rather than the three-fifths majority often needed for controversial legislation. That’s
Reagan’s first year in office, several deficitreduction packages through the 1980s and 1990s, and the tax cuts in 2001 and 2003. Reconciliation was used in 2010 to help pass the Affordable Care Act (ACA) and modify the federal student loan program, and then in 2016 in a vetoed attempt to repeal key elements of the Affordable Care Act.
Federal Budget Timetable Reconciliation and Authorizing Committees The committees that receive reconciliation instructions under the budget resolution are to report back to the budget committees by a date specified in the budget resolution. The Senate Finance Committee and House Ways and Means Committee usually receive such instructions. Then the budget committee in each house compiles a reconciliation bill historically called an Omnibus Budget Reconciliation Act (OBRA). These bills include the Balanced Budget Act of 1997 as one of the most (in)famous. Reconciliation bills are usually debated during the summer. At the end of the fiscal year in September, the reconciliation bills theoretically are approved by both houses and then signed or vetoed by the president. The tussle over passage of a reconciliation bill between the Senate and House and between the Congress and the White House goes late into the fall depending on whether it is an election year. In recent years there has not been a reconciliation bill. While there was a budget theoretically for FY 2018 and reconciliation instructions they have generally been ignored except when politically expedient. Under Senate interpretations of the Congressional Budget Act, the Senate can consider the three basic subjects of reconciliation — spending, revenues and debt limit — in a single bill or multiple bills, but it can consider each of these in only one bill per year (unless Congress passes a second budget resolution). Consequently, in the Senate there can be a maximum of three reconciliation bills in a year, one for each of the basic subjects of reconciliation. This rule is most significant if the first reconciliation bill that the Senate takes up affects both spending and revenues. Think of taxes and Medicare. Even if that bill is overwhelmingly devoted to only 14
On or Before:
Action to be completed:
First Monday in February
President submits his budget.
February 15
Congressional Budget Office submits report to Budget Committees.
Not later than six weeks after the president submits the budget.
Committees submit views and estimates to budget committees. (Frequently, the House Budget Committee sets its own date based on the Legislative Calendar).
April 1
Senate Budget Committee reports concurrent resolution on the budget.
April 15
Congress completes action on the concurrent resolution on the budget. (This is not signed by the president).
May 15
Annual appropriation bills may be considered in House.
June 10
House Appropriations Committee reports last annual appropriation bill.
June 15
Congress completes action on reconciliation legislation. (If required by the budget resolution).
June 30
House completes action on annual appropriation bills.
October 1
Fiscal year begins.
because reconciliation legislation is not subject to filibuster. For a reconciliation bill, however, the Congressional Budget Act limits Senate debate on the bill to 20 hours and limits debate on the subsequent compromise between the two houses to 10 hours. While the special procedures limit the time for debate, they do not limit the number of amendments that can be offered during the Senate’s initial consideration of the bill. As a result, once the 20-hour limit has expired, remaining amendments are considered with little or no debate.
The above outlines the statutory process. In recent years while Congress began the formal budget process, it was generally ignored, not completed or used when it is advantageous for certain political purposes, usually because of the special voting requirements allowed in the Senate. AMRPA will watch the budget and the process closely to see if there is any potential impact looming for inpatient rehabilitation providers. While current political chatter leans toward no large adverse changes for Medicare, we will watch it closely as well as continued proposed changes to the ACA.
In the Senate, any amendments offered to a reconciliation bill must be germane in order to prevent disputes over tangentially related or unrelated amendments, as often happens under regular Senate procedures. Congress first utilized the process in 1980. As examples, it used reconciliation to enact major spending cuts during President AMRPA Magazine March 2018
MORE DETAILS EMERGE ON BPCI ADVANCED By Mimi Zhang, Senior Policy and Research Analyst, AMRPA
I
n the weeks since the Centers for Medicare and Medicaid Services (CMS) announced its new Bundled Payment for Care Improvement Advanced (BPCI Advanced), the agency has shared more information about the model and its various programmatic details. These have come in the form of new documents or public open door forum webinars. It is clear that, ahead of the March 12 application deadline, providers and other health care stakeholders have many questions for CMS as they contemplate whether BPCI Advanced is a good fit for them to engage in bundled payments. During a January 30 webinar, for instance, CMS stated that it had
received more than 600 questions within three weeks and was working to address them all. The February issue of the AMRPA magazine included an article profiling BPCI Advanced that was based on details released to date at that time. This article reviews additional elements of BPCI Advanced, such as the financial methodology and key changes from the current BPCI program, and incorporates new information shared by CMS. Inpatient rehabilitation hospitals and units (IRH/Us) and other post-acute care (PAC) providers are not able to serve as Episode Initiators in BPCI Advanced, only acute care
Highlights: •
•
CMS shares more details about voluntary bundled payment program as application deadline nears. Additional specifics about pricing methodology and quality measures to come soon.
hospitals (ACH) or physician care practices (PGP) are eligible. CMS says that PAC providers can participate as a Convener or by partnering with a Convener as a NPRA Sharing Partner
Key BPCI Advanced Terminology • A Convener Participant brings together multiple downstream Episode Initiators, facilitates coordination among them, and bears and apportions the full financial risk. • A Non-Convener Participant, on the other hand, bears financial risk only for itself and does not bear financial risk on behalf of multiple downstream Episode Initiators. Only ACHs and PGPs can be Non-Convener Participants. • Episode Initiator: An Episode Initiator can trigger a clinical episode. Under BPCI Advanced, only ACH and PGPs can be Episode Initiators. • Participating Practitioner: A Medicare-enrolled physician or non-physician practitioner (e.g., nurse practitioner, physician assistant, or physical therapist) who: 1) is participating in care activities related to the overall care of BPCI Advanced beneficiaries during an episode, and 2) has entered into an agreement with the BPCI Advanced Participant that meets CMS’ agreement requirements. • Benchmark Price: A metric used by CMS, together with the CMS Discount, to calculate an Episode Initiator-specific Target Price for each Clinical Episode. The Benchmark Price is derived from historical Medicare FFS spending and adjusted for other factors. • Target Price: The Benchmark Price minus the CMS Discount, which is 3 percent under BPCI Advanced. • Net Payment Reconciliation Amount (NPRA): If applicable, the amount paid to a Participant by CMS, if the summed total of all total reconciliation amounts after adjusting for quality is positive. • NPRA Sharing Partner: A Participating Practitioner or clinician who is employed by an ACH Participate or Episode Initiator, ACH, PGP, ACO or PAC provider that 1) is involved in BPCI Advanced care activities; 2) is identified as such on the Financial Arrangement Screening List; and 3) has entered into a written NPRA Sharing Agreement that meets CMS’ requirements for the agreement.
15
(see Terminology sidebar). Being a Convener would entail bearing and apportioning risk for all episodes initiated by an ACH or PGP. Financial Methodology: Pricing, Reconciliation and Payment In order to generate program savings, CMS will deduct 3 percent from the Benchmark Price for any given clinical episode to generate the Target Price. The Benchmark and Target Prices are specific to each Episode Initiator and are based on the hospital’s historical spending for a clinical episode. The Benchmark Price is adjusted for several factors: •
Patient characteristics and case mix -- The patient characteristics include demographic data, comorbidities (Hierarchical Condition Categories), and patient severity, among other variables.
•
Patterns of spending relative to the hospital’s peer group over time -- Peer group characteristics will be adjusted using a Peer-Adjusted Trend (PAT) factor. PAT components include census region, urban/rural, and hospital size, among others. The PAT is a new prospective adjustment to target prices that is conceptually unrelated to the National Trend Factor being used in BPCI Models 2-4.
•
Historic Medicare FFS expenditure efficiency in resource use specific to the hospital’s baseline period.
The initial baseline period is the four-year period from January 1, 2013, to December 31, 2016. Benchmark Prices for physician practice groups (PGPs) will be slightly modified though they will be anchored in acute care hospital (ACH) pricing. CMS says it will release additional specifications on the pricing methodology to the BPCI Advanced website in February. Before a Model Year begins, CMS will inform participants of the preliminary Target Price (again, that is the Benchmark Price minus 3 percent). At the time of reconciliation, however, CMS will use a final Target Price that will be adjusted to reflect the actual case-mix of patients treated in the model. In the current BPCI program, CMS does not prospectively inform participants of their Target Price and this price is based only on historical levels of spending and patient mix. The new approach in BPCI Advanced, to adjust for the mix of 16
patients treated in the model, is likely due to patient selection trends or “cherry-picking” observed by CMS in the current BPCI. In both BPCI Models 2 and 3, the patient mix appeared to be healthier (and therefore less costly) once providers began participating in BPCI. BPCI Advanced Participants will be financially at risk for up to 20 percent of the final target price for each clinical episode they select. Participants are able to participate in Financial Arrangements under BPCI Advanced and thereby share Medicare payments or repayment owed with its partners in the model. However, the apportioned amounts cannot exceed 50 percent of the total Medicare FFS expenditures included in Clinical Episodes attributed to the participant. In other words, the participant must hold accountability for at least 50 percent of total risk. Additional details on the financial framework include: •
Target prices will change as the program progresses and the preliminary target prices will be rebased annually starting Model Year 3 on January 1, 2020.
•
The Stop-Loss/Stop-Gain limit is 20 percent and applied at the Episode Initiator level. This approach to payment is a change from current BPCI where Stop-Loss/Gain is set at the BPCI Awardee level.
•
One preliminary prospective price will be provided for all major joint replacement of the lower extremity episodes inclusive of elective procedures and fractures. This price will incorporate the proportion of fracture versus non-fracture episodes that occurred during the baseline period.
•
Claims will be reconciled semiannually, versus quarterly in current BPCI. Episodes that end on/before June 30 will be reconciled in the fall, and episodes ending before December 31 will be reconciled in spring of the next year.
•
The first Model Year is technically a model quarter as it runs from October 1 – December 31, 2018.
Quality and Pay-for-Performance In BPCI Advanced, payment will be linked to quality using a pay-for-performance methodology based on a participant’s
performance on specific quality measures and, if applicable, the quality performance of the participant’s partners in the model. •
These scores will be scaled, benchmarked and combined to generate a Composite Quality Score (CQS) and associated CQS Adjustment Amount for each Clinical Episode attributed to an Episode Initiator.
•
The CQS Adjustment Amount will then be applied to the net positive or negative reconciliation amounts to produce either the NPRA payment (amount to be paid by CMS) or the Repayment Amount (owed by the participant to CMS).
•
In the first two model years, the amount by which the CQS can adjust the Reconciliation Amount is capped at +/- 10 percent.
Despite quality-linkage being a hallmark of the BPCI Advanced framework as an Advance APM, there is limited detail released to date regarding how the quality measures will be selected, weighted, tied to financial performance, or regarding parameters for what it may consider acceptable quality measures. Some of these factors may be determined on a case-by-case basis specific to the participant, their selected clinical episodes, and their tolerance for financial risk. CMS says it will release more detailed information on the pay-for-performance methodology in coming weeks, including a table listing all the quality measures in BPCI Advanced and how they relate to the 32 clinical episodes. Waivers CMS has requested fraud and abuse waivers for BPCI Advanced to allow gainsharing and sharing in NPRA payments. These waivers will permit Participants to share Medicare payments or repayments with their provider partners. CMS intends for the waivers to be effective beginning October 1, 2018, and available to applicants for review prior to the execution of the BPCI Advanced Model Participation Agreement. CMS will also provide the following payment policy waivers or incentives: •
Skilled Nursing Facility (SNF) threeday rule: Medicare coverage is allowed for SNF care with less than AMRPA Magazine March 2018
three-day hospital stay •
Telehealth waiver: Medicare coverage for telehealth is expanded to include additional care settings (e.g., home) in all geographic areas.
•
Post-Discharge Home Visit Waiver: Medicare coverage for home visits after a hospitalization does not require direct physician supervision
•
Beneficiary Incentive waiver: Participants may offer “in-kind” items or services that are not Medicare-covered items or services, to a beneficiary that is related to the episode (e.g., transportation, equipment).
Advanced APM and CEHRT Requirement The BPCI Advanced Model was designed to meet the criteria of being an Advanced APM under the Quality Payment Program (QPP), which are as follows: •
•
•
The first criterion is the model must require participants to bear risk for monetary losses of more than a nominal amount under the model. The second criterion is that participants are required to use Certified Electronic Health Record Technology (CEHRT). In BPCI Advanced participants will be required to attest to their use of CEHRT prior to participating in the model. The third criterion is that payments under the model must be linked to quality measures comparable to MIPS quality measures. QPP-eligible clinicians who meet the patient count or payment thresholds under BPCI Advanced may become qualified APM participants -- QPs -- and eligible to receive the five percent APM incentive payment. The first date for QP determination will be March 31st, 2019.
Interplay with Other CMS Models The current BPCI Models 2-4 will conclude on September 30, 2018. The first BPCI Advanced Model Year is set to start the next day, October 1, 2018. At this time, CMS has not signaled that it would extend BPCI Models 2-4 beyond October 2018. CMS has laid out precedence rules regarding its various mandatory and voluntary bundled payment models:
•
The Comprehensive Care for Joint Replacement (CJR) mandatory program takes precedence over BPCI Advanced for those conditions under CJR, i.e., lower extremity joint replacements (LEJRs). In other words, hospitals that are mandatory participants in CJR will not be allowed to conduct voluntary BPCI Advanced bundles for LEJR episodes.
•
Slightly complicating this interplay is the current BPCI, which takes precedence over CJR but only until BPCI terminates on September 30.
•
At that time, any acute care hospitals located in a metropolitan statistical area (MSA) designated as a mandatory CJR MSA must participate in CJR, since as their BPCI LEJR episodes will have concluded. They will not be able to participate in BPCI Advanced with LEJR episodes.
Application Process and Claims Data Received The applications, submitted to CMS by March 12, are non-binding. Over the summer, applicants will be provided claims data to review and inform their selection of the Clinical Episodes they choose to participate in. Applicants will lock in their participation by executing BPCI Advanced Participation Agreements with CMS in August. CMS expects to distribute preliminary target prices to applicants in May 2018. Applicants must submit a Data Request and Attestation form. They can request aggregate historical and/or raw historical claims data prior to selecting Clinical Episodes. Both datasets will include claims from the final three years of the initial four-year baseline period (i.e., January 1, 2014 – December 31, 2016) for claims items related to all of BPCI Advanced’s Clinical Episodes. Line level data will include: inpatient, outpatient, carrier Part
Key Differences: BPCI vs. BPCI Advanced BPCI
BPCI Advanced
48 Inpatient Clinical Episodes
29 Inpatient and 3 Outpatient Clinical Episodes
Not an Advanced APM (lacks CERHT requirement and payment is not tied to quality)
Model is an Advanced APM
No quality measures required for payment purposes
Quality measures are reportable and performance on these measures will be tied to payment
Excludes cost of care associated with services according to 13 unique exclusion listings of “unrelated” care
Limited exclusions, but does exclude Part A and B costs associated with a qualifying hospital readmission based on a limited set of MS-DRGs
Model 3 includes episodes initiated by PAC providers
No equivalent for Model 3; program design is most similar to Model 2 with PGPs and ACHs as episode initiators
Risk corridor of 20 percent of spending about the upper limit of the selected risk track
One risk track, and risk is capped at +/- 20 percent
Target Prices provided at reconciliation
Preliminary Target Prices provided prospectively before the start of each Model Year
Next Generation Accountable Care Organizations (ACOs), Medicare Shared Saving Program (MSSP) Track 3, and the Comprehensive ESRD Model will also take precedence over BPCI Advanced. Beneficiaries in these models will be excluded from triggering episodes in BPCI Advanced.
B, durable medical equipment (DME), postacute care, hospice, and diagnosis procedure and diagnosis/procedure code research identifiable files. Applicants will receive data and target prices for all clinical episodes for which there are sufficient historical volume. More information on BPCI Advanced is available at https://innovations.cms.gov/ initiatives/bpci-advanced. 17
CMS WITHDRAWS RECENTLY ISSUED IRF GUIDANCE BOOKLET AFTER AMRPA INQUIRIES; OTHER NEW GUIDANCE REMAINS By Jonathan M. Gold, JD, Regulatory and Government Relations Counsel, AMRPA
I
n December, AMRPA informed members about several new guidance documents from the Centers for Medicare and Medicaid Services (CMS) pertaining to inpatient rehabilitation facility (IRF) coverage requirements. One of these documents was the Medicare Learning Network (MLN) booklet, titled IRF Reference Booklet, and it went through most parts of the Medicare IRF coverage requirements and provided example scenarios to assist with understanding of the various rules. After a careful review and soliciting feedback from member providers on this booklet, AMRPA staff raised concerns to CMS about incorrect interpretations and applications of Medicare policy in the IRF Reference Booklet. In response, CMS recently informed AMRPA that it agreed that this booklet is misleading and contained errors, and removed the document from its website. CMS further advised that it does not recommend providers use the document to inform practices. The other three recently issued documents still remain on CMS website, and AMRPA has been soliciting member feedback on their contents. The first of these coverage documents is MLN article Inpatient Rehabilitation Facility (IRF) Medical Review Changes. This article provides information about updated instructions that CMS recently issued to Medicare review contractors regarding the standards to use when reviewing claims for compliance with the intensity of therapy requirements in IRFs. The article states that CMS has instructed the contractors that when the 15 hours 18
per week of therapy requirement has not been met, the contractor should use its clinical judgement to determine the medical necessity of the claim based on the individual facts and circumstances of the case, and not on any time threshold. Further, CMS sought to clarify its policy on the use of group and concurrent therapy in an IRF by stating that group and concurrent therapy can be used on a limited basis “within the current industry standard” of three hours of therapy per day, but that justification will need to be well documented in the medical record. The second document is the standard IRF denial reason codes and statements. CMS states that they created these standardized denial reasons and codes because different contractors often used different codes and phrasing, and that by standardizing the codes CMS would lessen the burden on providers and allow for a better understanding of the reason for denial. CMS issued an initial version of these codes in the fall before withdrawing and reissuing them in December, apparently to conform with the new instructions it had given to contractors regarding therapy requirements in IRFs. The biggest change in these new universal codes and statements is that they will all now reference a specific IRF regulation or section of the Medicare Benefit Policy Manual (MBPM) when issuing a denial. Also notable is that CMS replaced denial statement “IRF8B” in the initial list of statements with a new statement. Previously the statement read: The documentation does not support the specific rationale for the
use of (concurrent/group) therapy for week NN for NN minutes of (OT/ PT) therapy. The standard of care for IRF patients is individualized (i.e., one-on-one) therapy. Group/ concurrent therapies serve as an adjunct to individual therapies. That statement has now been replaced with the statement, “Documentation does not support the patient received intensive rehabilitation therapy services.” There is no longer a denial statement that allows an IRF to be denied due to a lack of a specific amount of minutes of therapy being delivered. This indicates that CMS is further attempting to get CMS contractors to conduct a more individualized review of claims, rather than holding providers to a strict time threshold. Finally, CMS has also compiled all the coverage requirement clarifications it has issued pertaining to IRF coverage requirements into one document. This document contains clarifications issued by CMS at various points in time and covers many different areas of the IRF coverage requirements. This document does not contain any new clarifications, but just compiles previously issued clarifications in to one document. All of these documents are available for your review on the AMRPA website under the “Advocacy” tab. AMRPA continues to be interested in any provider feedback on the documents, including the need for further clarification or any errors identified with the documents. If you have comments on these documents, email Jonathan Gold at jgold@amrpa.org.
AMRPA Magazine March 2018
CALL FOR ABSTRACTS & POSTERS Visit us at amrpa.org to submit your abstract! Deadline for submission is: April 16, 2018
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MEDICARE PART B PAYMENT INCREASES WILL OFFSET 340B DRUG REIMBURSEMENT CUTS, AVALERE SAYS
N
ew research from Avalere Health finds that 85 percent of hospitals will see a net increase in their overall Medicare Part B reimbursement as a result of recent Medicare outpatient payment changes. The calendar year (CY) 2018 Outpatient Prospective Payment System (OPPS) final rule reduced Medicare’s payment for Part B drugs purchased under the 340B Drug Pricing Program. The 340B program allows some hospitals and health care providers that treat low-income patients to purchase certain outpatient drugs at discounted prices. Expressing concern about the growth in the number of providers participating in the 340B program and the high and increasing prices of certain drugs, the Centers for Medicare and Medicaid Services (CMS) finalized a policy late last year to lower 340B payments from an average sales price (ASP) plus 4.3 percent to ASP minus 23.7 percent effective January 1, 2018. This would reduce Part B drug payments to the impacted hospitals by $1.6 billion in 2018. Certain hospitals will be excluded from this policy, including rural sole community hospitals, PPS-exempt cancer hospitals, and children’s hospitals. CMS would implement this policy in a budget neutral manner and reallocate any savings from the 340B drug payment cut to payments for other non-drug items and services paid under the OPPS. To better understand the
20
overall impact of the OPPS payment policies, Avalere modeled Part B drug spending cuts to affected 340B hospitals. Methods In the analysis, Avalere: •
Identified Medicare Part B payments using 2016 claims data, separating drug payments from other Part B services.
•
Adjusted Part B drug payments to simulate the payment under ASP -23.7 percent methodology. (The budget sequestration of 2013 reduced the Part B add-on payment to 4.3 percent; the sequester would further reduce the proposed OPPS B payment rate from -22.5 percent to -23.7 percent)
•
Assessed overall OPPS payments impact reported by CMS.
•
Estimated non-drug OPPS payment changes.
•
Stratified data and results to demonstrate impact on specific subsets of hospitals.
The analysis reflects 3,814 hospitals paid under OPPS, not including 53 children’s and 11 free- standing cancer “held harmless” hospitals that receive proportional adjustments to their OPPS payment rates and are excluded from CMS’ impact file. Those hospitals are not subject to the Part B drug payment reduction even though they are 340B-eligible. Similarly, critical access hospitals (CAH) and hospitals located in Maryland are eligible for 340B prices but not paid under OPPS methodology.
Highlight: •
Avalere found that despite 340B payment cuts in 2018, hospitals will see an average 1.5 percent increase in their total Part B payments, rural hospitals gain a net 2.7 percent increase in payments, and urban hospitals will see a 1.4 percent net increase.
Findings Avalere’s analysis found that the 340B cuts will be offset by increases in other Medicare Part B payments. Across all facilities, hospitals will see an average 1.5 percent increase in their total Part B payments, rural hospitals gain a net 2.7 percent increase in payments, and urban hospitals will see a 1.4 percent net increase. Furthermore, among the 15 percent of all hospitals that will experience a net payment reduction, the majority (76 percent) will see cuts less than 5 percent of their overall outpatient reimbursement. More than half (55 percent) of total disproportionate share hospitals (DSH) — i.e., hospitals that serve a disproportionate number of low-income patients—will see payment increases more than offsetting the 340B drug reimbursement cuts. For the website.
announcement,
see
Avalere’s
AMRPA Magazine March 2018
GAO: CMS NEEDS TO IMPROVE THE EFFICIENCY OF THE HOME AND COMMUNITY-BASED SERVICES PROGRAM
R
ecent initiatives by the Centers for Medicare and Medicaid Services (CMS) related to home and community-based services (HCBS) programs are intended to help states evaluate the effectiveness of HCBS programs by addressing potential conflicts of interest that may occur when HCBS providers, or the managed-care companies contracted to administer HCBS benefits, have a financial interest in the outcome of needs assessments and are the entities conducting these assessments. In the January report, CMS Should Take Additional Steps to Improve Assessments of Individuals’ Needs for Home-and Community-Based Services, the Government Accountability Office (GAO) evaluated steps CMS has taken to improve the coordination and effectiveness of needs assessment processes for HCBS programs. The GAO assessed HCBS programs in six states and found that CMS could be more consistent in how it requires states to avoid or mitigate the potential for conflicts of interest in conducting HCBS needs assessments.
Medicaid HCBS Programs The Medicaid HCBS program covers a wide range of services and supports to help individuals remain in their homes or live in a community setting. Individuals require HCBS because they are limited in their ability to care for themselves due to physical, developmental or intellectual disabilities, or to chronic conditions. States often tailor their HCBS programs for certain populations, including: •
Older adults and people with physical disabilities,
•
People with intellectual or developmental disabilities,
•
People with addictions or mental illness, and
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Other populations with specific conditions such as traumatic brain injury (TBI) or Alzheimer’s disease.
The HCBS program can assist beneficiaries with activities of daily living (ADLs)—basic, personal, everyday activities such as bathing, dressing, and eating—or with instrumental ADLs, which are other activities that allow
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Conflicts of interest can result in inaccurate assessments, leading to unnecessary services or restricting beneficiaries’ access to needed services.
individuals to live independently in the community, such as meal preparation or managing finances. States generally assess a beneficiary’s needs for HCBS based on designated assessment tools—or sets of questions—that assessors use to collect information from sources such as beneficiaries, caregivers and health records. Needs assessment are used to inform determinations of whether an individual is eligible for state Medicaid HCBS programs, and they helpful inform the development of a service plan for eligible beneficiaries. Examples of the assessed needs include: •
Functional support needs: The need for assistance with ADL or instrumental ADL.
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•
•
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Cognitive and behavioral support needs: The loss of memory function, behaviors that pose risks or adaptive and maladaptive behaviors.
States use different delivery systems to provide Medicaid HCBS, and these may vary across distinct HCBS programs within a state. Historically, states have predominantly provided HCBS using fee-for service (FFS) delivery systems in which states pay providers directly. Alternatively, under managedcare long-term services and supports (LTSS) delivery systems, states contract with managed-care plans to provide HCBS to beneficiaries and typically reimburse the plans through capitation payments. Managed-care plans may contract with HCBS providers to provide services to beneficiaries or may provide services directly. States may also use a combination of fee-for-service and managed-care delivery systems. Needs Assessment Process The needs assessment processes may vary across states and distinct HCBS programs within a state, but typically involves the following key steps (see Figure 1): •
States direct potentially eligible individuals to entities that conduct Medicaid HCBS needs assessments.
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An assessor conducts a needs assessment, generally in a face-to face setting, using a designated assessment tool to collect information to determine a beneficiary’s functional eligibility for services.
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GAO’s Findings •
CMS has taken steps to improve needs assessments but concerns about conflict of interest remain in regard to HCBS providers and managedcare plans. HCBS providers may have a financial interest in the outcome of needs assessments, which could lead to overstating needs and overprovision of services.
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CMS has addressed risks associated with HCBS provider conflicts, such as by requiring states to establish standards for conducting certain needs assessments, but these requirements do not cover all types of HCBS programs. Specific conflict of interest requirements are generally not in place for needs assessments that are used to inform HCBS eligibility determinations. Also requirements for states to establish standards to address HCBS providers' potential for conflict of interest in conducting needs assessments that are used for service planning do not apply across all programs.
Beneficiaries’ strengths, preferences and goals.
HCBS Delivery Systems States can have multiple HCBS programs operating under different authorities that can have distinct features such as different functional eligibility criteria. For example, some types of Medicaid HCBS programs only serve beneficiaries who are functionally eligible for an institutional level of care; that is, beneficiaries must have needs that rise to the level of care usually provided in a nursing facility, hospital or other institution.
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included in this needs assessment, or collected in additional assessments that may occur after an individual is determined eligible for HCBS.
Clinical care needs or medical health concerns: Information on an individual’s health history, active diagnoses, medications and clinical services (e.g., wound care or dialysis).
Additional information relevant for service planning purposes may be
Managed-care plans may have a financial interest in the outcome of HCBS assessments used for both determining eligibility and service amounts. Managed-care plans could have an incentive to enroll beneficiaries with few needs, as plans typically receive a fixed payment per enrollee. For example, a plan in one state admitted in a settlement with the federal government to enrolling 1,740 individuals, from 2011 through 2013, whose needs did not qualify them. In 2013, CMS issued guidance that managed-care plans may not be involved in assessments used to determine eligibility for HCBS, but CMS has not consistently required states to prevent this involvement. Among three states GAO reviewed with managed-care HCBS programs, CMS required one to stop allowing plans to conduct such assessments but allowed plan involvement in two states. The absence of conflict-of-interest requirements across all types of HCBS programs and states is not consistent
with federal internal control standards, which require agencies to respond to risks to program objectives. HCBS needs assessments can directly affect whether individuals are eligible to receive HCBS and the amount of services they receive. Given the growth in spending for Medicaid HCBS and the potential vulnerability of individuals seeking HCBS, it is critical that needs assessments are effective in ensuring that beneficiaries receive the help they need to live independently while at the same time reducing the risk of over-utilization of HCBS. CMS plays an important role in ensuring that states appropriately assess the needs of those seeking HCBS, including addressing the potential for entities that conduct needs assessments to have conflicts of interest. Conflicts of interest can result in inaccurate assessments, potentially leading to provision of unnecessary services or restricting other beneficiaries’ access to needed services. CMS has required states to take actions to avoid or mitigate the potential for conflicts of interest for some HCBS programs, and states that have taken steps to protect against conflicts of interest in HCBS programs have reported improvements; however, GAO found gaps in federal requirements for such safeguards. These gaps in requirements are inconsistent with federal control standards that require federal agencies to identify, analyze and respond to risks related to achieving defined objectives. GAO Recommendation GAO recommended CMS improve the efficiency and effectiveness of Medicaid HCBS programs by consistently requiring that all types of states’ programs avoid or mitigate the potential for conflicts of interest in conducting needs assessments. It further recommended that CMS ensure that all Medicaid HCBS programs have requirements for states to address both service providers' and managed-care plans' potential for conflicts of interest in conducting assessments. CMS concurred with GAO's recommendation. For the complete report, see the GAO website. AMRPA Magazine March 2018
BRAIN-SCAN GUIDED EMERGENCY STROKE TREATMENT LED TO BETTER OUTCOMES, NIH FINDS
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dvances in brain imaging can identify a greater number of stroke patients who can receive therapy later than previously believed, according to a new study published in the January 24 issue of the New England Journal of Medicine. The study was also presented at the recent International Stroke Conference 2018 in Los Angeles. The study was funded by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health (NIH). According to the Medicare Payment Advisory Committee (MedPAC), almost 20 percent of Medicare beneficiaries treated in inpatient rehabilitation hospitals and units (IRH/Us) in 2015 were stroke patients. Ischemic stroke occurs when a cerebral blood vessel becomes blocked, cutting off the delivery of oxygen and nutrients to brain tissue. Brain tissue in the immediate area of the blockage, known as the core, typically cannot be saved from dying, and it can enlarge over time. However, it has long been thought that the area surrounding the core (known as the ischemic penumbra) has the potential to be saved based on how quickly blood flow can be restored. Over the past two decades, scientists have worked to develop brain scanning methods, called perfusion imaging, that
could identify patients with brain tissue that can still be salvaged by removing the blockage. In perfusion imaging, a standard dye is injected and scanned as it passes through the brain. DEFUSE 3 Trial The Endovascular Therapy Following Imaging Evaluation for the Ischemic Stroke (DEFUSE 3) was a large, multi-site study at 38 centers nationally supported by NINDS’ StrokeNet, a network of hospitals providing research infrastructure for multi-site clinical trials. The results from the DEFUSE 3 trial demonstrated that physically removing brain clots up to 16 hours after symptom onset in selected patients led to improved outcomes compared to standard medical therapy. The researchers believe that this could open the door to treatments even for some patients who are unable to arrive at the hospital until many hours after their initial symptoms. Using an automated software known as RAPID to analyze perfusion MRI or CT scans, the DEFUSE 3 researchers identified patients thought to have salvageable tissue up to 16 hours after stroke onset. The participants were randomized to either receive endovascular thrombectomy plus standard medical therapy or medical therapy alone.
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NIH-funded study finds patients treated up to 16 hours after stroke showed positive outcomes.
Endovascular thrombectomy, or the physical removal of the blockage, is currently approved for use up to six hours following onset of stroke symptoms. However, the study researchers discovered that this intervention can be effective up to 16 hours after symptoms begin in this select group of patients. The findings showed that patients in the thrombectomy group had substantially better outcomes 90 days after treatment compared to those in the control group. For example, 45 percent of the patients treated with the clot removal procedure achieved functional independence compared to 17 percent in the control group. In addition, thrombectomy was associated with improved survival. According to the results 14 percent of the treated group had died within 90 days of the study, compared to 26 percent in the control group. For the announcement, see the NIH website.
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WEARING BIOSENSORS DOES NOT SIGNIFICANTLY IMPROVE PATIENT OUTCOMES, STUDY FINDS
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earable biosensors have grown increasingly popular as many people use them in wristbands or watches to count steps or track sleep. But there is not enough proof that these devices are improving patient outcomes such as weight or blood pressure, according to a study by Cedars-Sinai investigators published in the new Nature partner journal, npj Digital Medicine. Wearable biosensors—noninvasive devices that automatically transmit data to a web portal or mobile app for patient self-monitoring or health provider assessment—have been widely publicized as a means to reduce health care utilization, decrease costs, generate research data and increase physician satisfaction. Investigators at Cedars-Sinai Medical Center in Los Angeles conducted a statistical analysis and in-depth literature review of 27 studies from 13 countries published between January 2000 and October 2016. Each study examined the effects of remote patient monitoring using wearable biosensors. The interventions targeted patients who were overweight or had heart disease, lung disease, chronic pain, stroke or Parkinson's. The devices studied included physical activity trackers, blood pressure monitors, electrocardiograms, electronic weight scales, accelerometers (devices measuring acceleration) and pulse oximeters (oxygen
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saturation monitors), among others. These devices were embedded in everything from watches and belts to skin patches and textiles. A statistical analysis of the relevant literature revealed that remote patient monitoring resulted in no significant impact on any of the reported clinical outcomes. Certain types of interventions worked best, including efforts grounded in social science models and established care guidelines and those that used personalized coaching. Findings In their literature analysis, the authors found that remote patient monitoring with these sensors had no statistically significant impact on any of six clinical outcomes studied: body mass index, weight, waist circumference, body fat percentage, systolic blood pressure and diastolic blood pressure. However, the analysis found that the devices did show early promise in improving patient self-management and possibly outcomes for certain conditions, including obstructive pulmonary disease, Parkinson's disease, hypertension and low back pain. Of more than 4,000 studies the authors initially reviewed, fewer than 1 percent were eligible to be included in the study, and only 16 were considered high-quality research. The authors found very few randomized controlled trials for each of the clinical outcomes analyzed, and studies
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While remote patient monitoring via biosensors do not significantly improve clinical outcomes, the devices show early promise in helping patient self-manage some chronic conditions such as obstructive pulmonary disease, Parkinson's disease, hypertension and low back pain.
varied significantly in terms of the types of devices used, the populations studied and the interventions tested. The study authors also note that many currently available consumer products have not yet been tested in randomly controlled trials with clinically meaningful outcomes. Although some consumer-facing digital health products may be effective for promoting behavior change, there is currently a dearth of evidence that these devices achieve health benefits, and that more research is needed in this field. The authors recommend patients, clinicians, and health system leaders proceed with caution before implementing and using remote patient monitoring to reliably change clinical outcomes. For the announcement, see the Cedars Sinai website.
AMRPA Magazine March 2018
STUDY FINDS ASPIRATION EFFECTIVE IN STROKE INTERVENTIONS
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new study has found that patients suffering a large vessel occlusion stroke (LVO), the most devastating kind of ischemic stroke, do just as well when treated with a direct aspiration first pass (ADAPT) approach than those treated with a stent retriever first-line (SRFL) approach. Currently, SRFL is the standard of care for mechanical thrombectomy in patients suffering acute ischemic strokes. The findings were presented at the 2018 International Stroke Conference (ISC) in January and was co-led by researchers at the Icahn School of Medicine at Mount Sinai. A number of clinical trials published in 2015 demonstrated the superiority of endovascular thrombectomy (restoring blood flow to the brain by surgically removing the clot) over medical management (administration of clot busting drugs) for treatment of
ischemic strokes. The majority of stoke thrombectomy data to date has focused on stent retrievers, leading many to believe that they represented the gold standard of thrombectomy devices, as reflected by recent American Heart Association/American Stroke Association guidelines. The study results show that an aspiration-first strategy is at least as effective as using retrievable stents, and may even be faster, safer and cheaper. Both the aspiration and stent retriever techniques are initiated by inserting a guide catheter into the femoral artery in the groin and guiding it up into the brain under image guidance. •
The aspiration approach involves passing a specialized aspiration catheter through the guide catheter, moving it directly to the lesion and then attaching it to an aspiration pump. Once attached to the aspiration system, the catheter is advanced into the proximal end of
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Aspiration-first strategy is at least as effective as using retrievable stents and may be faster, safer and more economical.
the clot, suction is initiated and the clot is either aspirated through the catheter or it becomes stuck at the catheter tip and is withdrawn back into the guide catheter. •
The stent retriever approach involves introducing a stent retriever, which resembles a tiny wire cage, through the guide catheter and moving it to the clot. The stent then opens up, traps the clot and the stent that contains the clot is removed through the guide catheter
In the study, 270 patients were enrolled into a prospective, randomized, open25
label, blinded outcome assessment and core lab adjudicated trial to assess the clinical outcome of the patient - how functional they were after treatment with either ADAPT using a large-diameter aspiration catheter (ACE™68) system, made by Penumbra Inc., or a stent retriever as first-line approach. To compare clinical outcomes, researchers used the modified Rankin Scale for neurologic activity (mRS), a standard measurement of the degree of disability or dependence in the daily activities of people who have suffered a stroke, which runs from 0 (no symptoms at all) to six (deceased). The data showed that the ADAPT technique was non-inferior to stent retrievers for treatment of large vessel occlusions: 52 percent of patients treated with Penumbra’s aspiration
system achieved the primary endpoint of functional independence (mRS 0-2) at 90 days, compared with 49 percent of patients treated with stent retrievers. Quality of revascularization was comparable between the therapies, with the final rate of revascularization success (TICI 2b) being 92 percent and 89 percent, for ADAPT and stent retriever, respectively (p=0.54). Moreover, the percentage of patients achieving full reperfusion (TICI 3) was 38 percent for the ADAPT arm and 29 percent for the stent retriever arm (p=0.15).
the clot. It is the first trial designed to compare patient functional outcome between these treatment approaches, and found that patients do equally well with either treatment. To read the full announcement, see the Newswise website.
The study demonstrated that the ADAPT and SRFL approaches are clinically equivalent, and that patients do just as well when aspiration or clot suction is the first treatment intervention as compared to when a stent retriever is used to remove
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AMRPA Magazine March 2018
MACPAC ISSUES DATA BOOK ON DUAL-ELIGIBLE BENEFICIARIES
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n January 2018, the Medicaid and CHIP Payment and Access Commission (MACPAC) issued the annual Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid. Jointly produced by MACPAC and the Medicare Payment Advisory Commission (MedPAC), the data book presents information on the demographic and other personal characteristics, expenditures, and health care utilization of individuals who are dually eligible for Medicare and Medicaid coverage.
The 2018 data book provides information for calendar year (CY) 2013 also includes information on trends in the dual-eligible population between CY 2009 and CY 2013.
Dual-eligible beneficiaries receive both Medicare and Medicaid benefits by virtue of their age or disability and low incomes. This population is diverse and includes individuals with multiple chronic conditions, physical disabilities, and cognitive impairments such as dementia, developmental disabilities, and mental illness. For dualeligible beneficiaries, Medicare is the primary payer for acute and post-acute care services covered by that program. Medicaid provides varying levels of assistance with Medicare premiums and cost sharing and, for many beneficiaries, covers services not included in the Medicare benefit, such as long-term services and supports (LTSS). Fullbenefit dual-eligible beneficiaries receive the full range of Medicaid benefits offered in a given state. For partial-benefit dual-eligible beneficiaries, Medicaid pays Medicare premiums and may also pay the cost sharing for Medicare services.
For more information, the complete data book is available at https:// www.macpac.gov.
This article highlights key data tables and graphs that may be of interest to inpatient rehabilitation and post-acute care providers, such as program spending, dual-eligible beneficiaries’ patient characteristics, and enrollment in Medicare Advantage.
Medicare and Medicaid spending on dual-eligible beneficiaries by age and type of benefit, CY 2013
Note: CY (calendar year). Exhibit includes all dual-eligible beneficiaries (feefor-service, managed care, and end-stage renal disease). Medicaid spending amounts for dual-eligible beneficiaries exclude Medicaid payments of Medicare premiums. Totals may not sum due to rounding. Exhibit excludes administrative spending. Source: MedPAC | MACPAC Data book: Beneficiaries dually eligible for Medicare and Medicaid — January 2018 •
Combined Medicare and Medicaid spending on dual-eligible individuals was $312.4 billion in CY 2013. Medicare accounted for about 62 percent of combined spending ($193.5 billion).
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By age group, most spending on dual-eligible beneficiaries was for beneficiaries ages 65 and older ($189.3 billion in combined spending).
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Number of dual-eligible and non-dual Medicare and Medicaid beneficiaries, CY 2009-2013
Selected conditions for FFS dual-eligible beneficiaries by age group, CY 2013
Note: FFS (fee-for-service), CY (calendar year). Chronic conditions are identified using Medicare FFS claims. Exhibit excludes beneficiaries enrolled in Medicare Advantage plans because Medicare FFS claims are not available for those individuals. Beneficiaries with end-stage renal disease are also excluded. Note: CY (calendar year). Exhibit includes all dual-eligible and non-dual beneficiaries (fee-for-service, managed care, and end-stage renal disease). Medicaid beneficiaries include Medicaid-expansion Children’s Health Insurance Program enrollees. Individual figures shown are rounded; growth rates are computed based on unrounded numbers.
Source: Data book: Beneficiaries dually eligible for Medicare and Medicaid — January 2018 MedPAC | MACPAC •
The share of dual-eligible individuals with selected chronic conditions varied between those under age 65 versus those ages 65 and older.
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With respect to cognitive impairment, Alzheimer’s disease or related dementia was much more common among the older dualeligible beneficiaries (23 percent vs. 4 percent). More dual-eligible beneficiaries under age 65 had an intellectual disability (8 percent vs. 1 percent).
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Beneficiaries ages 65 and older generally had higher rates of medical conditions such as diabetes, heart failure, hypertension, and ischemic heart disease than younger beneficiaries.
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Behavioral health conditions—anxiety disorders, bipolar disorder, depression, and schizophrenia and other psychotic disorders—were consistently more common among the dual-eligible population under age 65 than those ages 65 and older.
Source: Data book: Beneficiaries dually eligible for Medicare and Medicaid — January 2018 MedPAC | MACPAC •
The number of dual-eligible beneficiaries grew from 9.2 million in 2009 to 10.7 million in 2013—a cumulative growth of 15.8 percent over the period and an average annual growth rate of 3.7 percent.
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The number of non-dual-eligible Medicaid beneficiaries grew at a similar rate, increasing from 54.6 million in 2009 to 62.9 million in 2013, for a cumulative growth of 15.1 percent and an average annual growth rate of 3.6 percent.
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The slowest growth was among non-dual-eligible Medicare beneficiaries. Although the number of nondual-eligible Medicare beneficiaries increased from 38.6 million in 2009 to 43.3 million in 2013, non-dual eligible Medicare beneficiaries had lower cumulative growth (12.2 percent) and lower average annual growth (2.9 percent) than the other two groups of beneficiaries.
Medicare fee-for-service and managed care enrollment, CY 2013
Note: CY (calendar year), FFS (fee-for-service), MA (Medicare Advantage). Exhibit includes all dual-eligible beneficiaries and non-dual Medicare beneficiaries (fee-for-service, managed care, and end-stage renal disease). Percentages may not sum to 100 due to rounding. Source: Data book: Beneficiaries dually eligible for Medicare and Medicaid — January 2018 MedPAC | MACPAC •
In 2013, individuals dually eligible for Medicare and Medicaid services (73 percent) were enrolled only in Medicare FFS.
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Dual-eligible beneficiaries ages 65 and older were more likely to be exclusively enrolled in a Medicare Advantage (MA) plan than those under age 65 (26 percent vs. 16 percent).
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Partial-benefit dual-eligible beneficiaries were more likely to be exclusively enrolled in an MA plan than full-benefit beneficiaries (32 percent vs. 18 percent), while full-benefit beneficiaries were more likely to be in FFS only (77 percent vs. 62 percent).
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AMRPA Magazine March 2018
Medicaid fee-for service and managed care enrollment, CY 2013
Items and services covered by Medicare and Medicaid
Note: CY (calendar year), FFS (fee-for-service). Exhibit includes all dualeligible beneficiaries (FFS, managed care, and endstage renal disease). The non-dual Medicaid beneficiary category excludes nondisabled Medicaid beneficiaries under age 65 and Medicaid beneficiaries ages 65 and older who did not have Medicare coverage. Percentages may not sum to 100 due to rounding. Source: Data book: Beneficiaries dually eligible for Medicare and Medicaid — January 2018 MedPAC | MACPAC •
Most dual-eligible individuals were either enrolled only in Medicaid FFS (52 percent) or in Medicaid FFS with a limited-benefit Medicaid managed care plan (31 percent).
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Non-dual Medicaid beneficiaries eligible on the basis of a disability were more likely than dual-eligible beneficiaries to have at least one month of enrollment in a comprehensive managed care plan (57 percent vs. 17 percent) and less likely to be enrolled in Medicaid FFS only (17 percent vs. 52 percent).
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Nearly two-thirds (63 percent) of full-benefit dual-eligible beneficiaries were enrolled in some type of Medicaid managed care plan during the year.
Note: SNF (skilled nursing facility). Certain Medicaid beneficiaries are not entitled to full benefits and receive a more limited set of services (see Table 1 for information on dual-eligible beneficiaries who receive limited Medicaid benefits). With certain exceptions, states may place limits on the coverage of mandatory and optional Medicaid benefits for beneficiaries, including those who are dually eligible. Source: Social Security Act and Centers for Medicare & Medicaid Services 2017c. Data book: Beneficiaries dually eligible for Medicare and Medicaid — January 2018 MedPAC | MACPAC
CMS EXTENDS TEMPORARY MORATORIA ON HOME HEALTH AGENCIES FOR SIX MONTHS The Centers for Medicare and Medicaid Services (CMS) has extended a temporary statewide moratoria on new home health agencies (HHAs) for six months in six states – Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey. The notice, published in the January 30, 2018, Federal Register, identified a high risk of fraud, waste, and abuse for home health agencies and nonemergency ambulance services in the six states. The extension also applies to the enrollment of new non-emergency ground ambulance suppliers and home health agencies, subunits, and branch locations in Medicaid and the Children’s Health Insurance Program (CHIP) in those states. For purposes of these moratoria, providers that were participating as network providers in one or more Medicaid managed care organizations before January 1, 2018, will not be considered “newly enrolling” when they are required to enroll with the state Medicaid agency pursuant to a new statutory requirement, and thus will not be subject to the moratoria.
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AMRPA FEDERAL ELECTION CENTER
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s part of AMRPA’s continuing efforts to ensure our members remain active in shaping their federal representation in Congress, we are providing updates on the upcoming midterm Congressional elections.
The following states will be holding primary elections in March:
Texas – March 5, 2018 Thirty-six House seats are up for election: 28 incumbents and eight vacant seats. Representatives Joe Barton (R), Blake Farenthold (R), Gene Green (D), Jeb Hensarling (R), Sam Johnson (R), Ted Poe (R) and Lamar Smith (R) have decided not to seek reelection. Incumbent Representative Beto O'Rourke (D) will be running for a seat in the Senate against incumbent Senator Ted Cruz. Illinois – March 20, 2018 Illinois has 18 House seats up for election: 17 incumbents and one vacant seat. Representative Luis Gutiérrez (D) has decided not to seek reelection. No Senate seats are up for election. The following states will be holding primary elections in May: Indiana – May 8, 2018 Nine House seats are up for election: seven incumbents and two vacant seats. Representatives Luke Messer (R) and Todd Rokita (R) are running for a seat in the Senate against incumbent Senator Joe Donnelly (D). North Carolina – May 8, 2018 North Carolina has 13 House seats: all incumbents are running for reelection. No Senate seats are on the ballot this year. Ohio – May 8, 2018 Ohio has 16 House seats in the delegation: 15 incumbents and one vacant seat. Representative Jim Renacci (R) will be running for the Senate seat against the incumbent Senator Sherrod Brown (D). West Virginia – May 8, 2018 Three House seats are up for election: two incumbents and one vacant seat. Representative Evan Jenkins (R) will be running against the incumbent Senator Joe Manchin (D) for a seat in the Senate. Idaho – May 15, 2018 Idaho has two House seats in the delegation, with one incumbent running for reelection and one vacant seat. Representative Raul Labrador (R) will be running for Idaho governor. No Senate seats are up for election.
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Nebraska – May 15, 2018 Nebraska has hree House seats. All incumbents are running for reelection. There is one Senate seat up for election. Incumbent Senator Deb Fischer (R) will be running for reelection.
Oregon – May 15, 2018 Five House seats are up for election. All incumbents are running for reelection. There are no Senate seats up for election. Pennsylvania – May 15, 2018 Pennsylvania has 18 House seats: 12 incumbents and six vacant seats. Representative Tim Murphy (R) resigned his position in October 2017. Representatives Robert Brady (D), Charles Dent (R), Patrick Meehan (R), and Bill Shuster (R) are not seeking reelection. Representative Lou Barletta (R) is running for a seat in the Senate against incumbent Senator Bob Casey Jr. (D). Arkansas – May 22, 2018 There are four House seats up for election. All incumbents are running for reelection. No Senate seats are up for election. Georgia – May 22, 2018 There are 14 House seats up for election. All incumbents are running for reelection. No Senate seats are up for election. Kentucky – May 22, 2018 Six House seats are up for election. All incumbents are running for reelection. No Senate seats are up for election. Be sure to visit our website for more up-to-date election information. The 2018 Congressional Elections page can be found under the Advocacy tab on www.amrpa.org. If you have any questions or feedback, contact Catherine Beal at cbeal@amrpa.org or +1-202223-1920. Finally, the following websites provide more information on getting involved with your local representatives or assistance with voting in the upcoming elections. Find your House representative here: www.house.gov/representatives/ find-your-representative and Senators here: www.senate.gov/general/ contact_information/senators_cfm.cfm. For more voting information, and to find out if you are registered, visit: www.usa.gov/voting.
AMRPA Magazine March 2018
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AMRPA Magazine March 2018