AMRPA Magazine April 2018

April 2018 • Vol. 21, No. 4

The Importance of Checking “Under the Hood” of Short-term Health Plans

April 2018 • Vol. 21, No. 4

The official publication of the American Medical Rehabilitation Providers Association AMRPA Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Manager Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA Mimi Zhang Senior Policy and Research Analyst, AMRPA Patricia Sullivan AMRPA Senior Editor Lovelyn Robinson AMRPA Contributing Editor Ryan Foster AMRPA Design and Layout

AMRPA Magazine, Volume 21, Number 4 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.

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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 / April 2018

Table of Contents Letter from the Chair

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AMRPA Legislative Update

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CMS Issues Clarification of Medical Necessity of IRH/U Claims: Clarifies Denials Based on Three Hour Rule

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Selecting the Impairment Group Code

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Administration Announces New Programs to Help Beneficiaries Access Their Health Care Data

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MedPAC Turns to Developing Accurate Payments for Sequential Stays in Post-Acute Care

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New Outpatient Therapy Billing Procedures Now in Effect

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AMPRA Spring Conference & Congressional Fly-In 2018

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Even Experienced Wheelchair Users Can Benefit from New Techniques to Reduce Upper Body Stress, Study Says

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GAO Examines Medicaid Demonstration Evaluations, Says Improvements are Needed

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Medicare Spending on Health Services Closely Linked to How Care is Delivered, Commonwealth Study Says

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NQF’s Measure Applications Partnership Recommends Measures for Federal Health Care Programs

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AMRPA Sends Letter to CMS on Access and Transparency Issues in the Medicare Advantage Program

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2018 Medicare Participating Post-Acute Care Providers in the U.S.

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2018 PPS-Excluded Inpatient Rehabilitation Hospitals and Units, Long-term Care Hospitals, CORFs and Beds By State

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Federal Elections Center

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Letter from the Chair

Richard Kathrins, PhD, President & CEO, Bacharach Institute for Rehabilitation RKathrins@bacharach.org

References Goldstein, A. (2018, Feb 20). Short-term health plans skirting ACA-required benefits and protections to be expanded. https://www.washingtonpost. com/national/health-science/ short-term-health-plans-skirting-acarequired-benefits-and-protections-tobe-expanded/2018/02/20/9889c7c614d3-11e8-92c9-376b4fe57ff7_story. html?utm_term=.b5fd3eba56ae Pear, R. (2018, Feb 26). Trump moves to relax rules on cheaper health insurance. https://www.nytimes.com/2018/02/20/us/ politics/trump-cheaper-health-insurance. html Rampell, C. (2018, Feb 20). Trump’s sneaky backdoor Obamacare repeal is working. https://www.washingtonpost.com/ opinions/these-buffalo-health-plans-area-load-of-bull/2018/02/26/c7292bc21b3a-11e8-ae5a-6e60e4605f3_story. html?utm_term=.a096e8624ec1

The Importance of Checking “Under the Hood” of Short-term Health Plans Short-term health plans (STHP) at times have met an important need for the consumer. STHP could bridge the divide between an insurance plan that might, for example, have lapsed and one that might be picked up at a later date (Pear, 2018). A proposal released by the Administration in late February would broaden the reach and appeal of these plans by extending them from a maximum of three months to a maximum of twelve (Goldstein, 2018). But like everything else, the devil is in the details. In this case, the details of extending the timeframe for STHP might prove to be problematic for the patients we see every day in rehabilitation settings.

These short-term policies have no requirements as to what services they must cover (Rampell, 2018). An article in the Washington Post quotes the administrator of the Centers of Medicare and Medicaid Services as saying, ”While in the past these plans have been a bridge, now they are a lifeline,” (as cited in Goldstein 2018, para 5).

// ...the details of extending the timeframe for STHP might prove to be problematic for the patients we see every day in rehabilitation settings.

Goldstein asserts that the idea is to make it easier for individuals and business to buy STHP that does not include the essential health benefits defined in the Affordable Care Act (ACA). In addition, these plans could deny coverage due to preexisting conditions or the premiums could be priced higher for consumers with poor health (Goldstein, 2018; Rampell, 2018).

Though STHP may be cheaper to purchase, in fact they may fail to cover services such as rehabilitation and habilitation. Rampell (2018) noted that in 2016 one short-term policy provider paid out only 47 cents of every dollar it received in premiums whereas the plans compliant with ACA often paid out at least 80 percent of the premiums collected. Pear (2018) stated that consumers who purchased STHP and developed serious illnesses, chronic diseases or injuries might face financial hardship until they enrolled in traditional ACA plans. While the policies would be expected to have a disclosure statement indicating that these STHPs might not comply with the ACA, it might be difficult for consumers to tell the differences between plans that would cover needed services from those that would not (Pear 2018; Rampell 2018).

We all understand the need to control the costs of health care while improving the quality of care. We also all understand that those who become injured or suffer a serious illness should have access to appropriate care in order to improve their quality of life. Cheaper health insurance should not drive our consumers to gamble with healthcare insurance coverage or risk financial hardship should an unfortunate event or illness occur that requires medically necessary rehabilitation services.

AMRPA Magazine / April 2018

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Legislative Update

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

Highlights: »»

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HHS Secretary Azar gives first big policy speech to hospital executives and calls for value-based care.

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The president released his FY 2019 Budget Request, containing numerous funding and policy proposals in the post-acute space.

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House and Senate Committees are gearing up for action on the opioid crisis, holding multiple hearings with the goal of passing a comprehensive package this year.

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House Ways and Means Committee Health Subcommittee Chair Peter Roskam (R-IL) is renewing the panel’s regulatory reform initiative, with the aim of passing bipartisan legislation by August.

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Appropriators face several hurdles in negotiations over the LaborHHS measure.

Congress faced a March 23 deadline to pass a FY 2018 Omnibus spending bill

AMRPA Magazine / April 2018

Members Negotiate Omnibus Ahead of March 23 Deadline As of the writing of this article, lawmakers are working to reach agreement on a $1.2 trillion Fiscal Year (FY) 2018 Omnibus spending bill that appropriators aimed to file by March 14. The government was operating under a Continuing Resolution (CR) through March 23 that passed with the Bipartisan Budget Act of 2018 (H.R. 1892). The Omnibus may include additional disaster relief aid for Puerto Rico and other affected areas. The final package could also be a vehicle for Affordable Care Act (ACA) market stabilization legislation pending in Congress.

A stabilization bill may include funding for State reinsurance programs and for cost-sharing reduction (CSR) payments the White House halted in October. Still, disagreements over specific policies may sink tentative plans for stabilization legislation. In addition, while it appears lawmakers will address divisive issues such as gun control and immigration separately, several funding and policy disputes are holding up the Labor, Health and Human Services, and Education appropriations measure. The House and Senate have not resolved differences over family planning grants and funding for abortion providers, while a separate issue regarding mandatory offsets to discretionary spending remains outstanding. Prolonged negotiations over the Labor-HHS bill could also delay consideration of the Omnibus package.

HHS Secretary Azar Lays Out Four-Pronged Vision to Achieve Value-Drive Care On March 5, HHS Secretary Azar spoke to Federation of American Hospitals executives and laid out an aggressive agenda for the Department of Health and Human Services (HHS) focused on 1) providing patients with health information and interoperable, accessible health information technology; 2) increased medical pricing transparency; 3) creating new delivery models under Medicare and Medicaid, including moving to value-based payments; and 4) removing regulations that may prevent these efforts.

He called out accountable care organizations (ACOs) for being “lackluster,” which he noted was likely due to reporting requirements and lack of risk for providers, and to expect "bold measures" from the Innovation Center that will move Medicare and Medicaid away from a volume-incentivized fee-for-service system. Azar expressed a strong desire to work with the private sector stating they should not just be seen as “entities to be regulated or overseen.”

He also suggested that “facilitating a competitive, value-based marketplace is going to be disruptive to existing actors.”

President’s Budget Request for FY 2019 On February 12, the Office of Management and Budget (OMB) released the president’s FY 2019 Budget Request. The budget requests $68.4 billion in discretionary funding for HHS, a $17.9 billion or 21-percent decrease from the 2017 enacted level. The budget also includes $1.1 trillion in mandatory and discretionary outlays for the Centers for Medicare and Medicaid Services (CMS), a net increase of $53.3 billion over FY 2018.

The budget proposal includes a number of provisions of interest to inpatient rehabilitation providers, including a proposal to implement a unified post-acute care (PAC) payment system

in FY 2024, with payments based on episodes of care and patient characteristics. Payments would be set prospectively on an annual basis and would be risk-adjusted. For FY 2019 to FY 2023, skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRFs) would receive a lower Medicare payment update. According to the HHS Budget in Brief, this proposal would save $80.2 billion over 10 years. Other proposals in the Budget include: reforms to the Medicare appeals process; implementation of the home health grouping model; expansion of prior authorization requirements for Medicare fee-for-service; and transfer of the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) to the National Institutes of Health (NIH).

It is unclear how many, if any, of the president’s legislative and budget proposals will move forward. Congress is the ultimate determiner regarding these proposals. It is critically important that the rehab hospital field clearly recognize and understand that we will most likely face aggressive congressional initiatives related to entitlement reform and budget deficit reduction, including in Medicare.

Opioid Response Congress is planning significant activity to begin to address the opioid crisis in the first half of this year, with a flurry of hearings and legislative activity already underway. On February 28, the House Energy and Commerce Committee held the first of three legislative hearings that it has planned on the opioid crisis. The hearing focused on the Controlled Substances Act and related enforcement issues, with members hearing from the Drug Enforcement Administration and an array of stakeholders on drug diversion, safe prescribing and medication-assisted treatment. Further hearings may stretch into April and will examine public health and reimbursement issues. Chair Greg Walden (R-OR) suggests that the committee will proceed under regular order, marking up legislation in April and moving a package to the floor by Memorial Day. Members hope to send a final package to the President’s desk by the August recess.

The Senate is also moving forward on addressing opioids; on February 27, the Health, Education, Labor and Pensions Committee held a hearing on the role of technology and data in combating the opioid epidemic. Chair Lamar Alexander (R-TN) stated that he expects the committee to mark-up opioid legislation at the end of March. Chair Alexander also met with governors to discuss opioid-related issues, and the committee held a hearing with a panel of governors on March 8 to hear their feedback. Meanwhile, a group of senators led

by Sens. Rob Portman (R-OH) and Sheldon Whitehouse (D-RI) has proposed a discussion draft to build on the Comprehensive Addiction and Recovery Act of 2016 (CARA). The bill, dubbed CARA 2.0, would authorize $1 billion in funding for evidence-based prevention, enforcement, treatment and recovery programs.

Ways and Means Deregulatory Initiative House Ways and Means Committee Health Subcommittee Chair Peter Roskam (R-IL) announced plans to finalize bipartisan legislation that aims to pare back burdensome health care regulations, an initiative launched last summer by his predecessor former Subcommittee Chair Patrick Tiberi (R-OH). Speaking at the Federation of American Hospitals’ annual conference on March 5, Roskam confirmed his intention to hold roundtables, a hearing, and subsequent legislative markup with the goal of sending a bill to the president’s

desk before the August recess. He noted that the committee has received hundreds of stakeholder submissions in response to the regulatory relief initiative. AMRPA submitted detailed proposals and recommended policy solutions in response to this initiative. AMRPA is planning to work with Roskam and committee staff to address several burdensome IRF policies and hopefully achieve inclusion in this potential legislative vehicle.

CMS MyHealthEData Initiative On March 6, CMS Administrator Seema Verma announced the launch of a new initiative called “MyHealthEData,” intended to give patients greater control of their health care data. The initiative is being led by the White House Office of American Innovation with participation from CMS, the Office of the National Coordinator of Health Information Technology, NIH, and the Department of Veterans Affairs. According to CMS, the initiative will empower patients to electronically receive a copy of their entire health record and share their data with the providers they choose.

CMS also announced the launch of Medicare’s Blue Button 2.0, which will allow Medicare beneficiaries to access and share their health data in a universal digital format. More than 100 organizations have signed on to use Blue Button 2.0 to develop secure applications for patients to use in connection with their data.

HHS Proposed Rule on Short-Term Limited-Duration Insurance The Departments of Treasury, Labor and Health and Human Services (HHS) released a proposed rule to expand the availability of short-term, limited-duration insurance plans (STLDIs). These plans are not required to cover essential health benefits and can exclude individuals with pre-existing conditions. The proposed rule would extend the maximum duration of such coverage from three months to 12 and allow renewals of STLDIs. Comments on the proposal are due April 23, 2018. (See AMRPA Board Chair Rich Kathrin’s column on page 3 of this issue.)

National Health Expenditures Projections The CMS Office of the Actuary on February 14 released its projected national health expenditures for 2017-2026. According to the report, national health spending growth is expected to average 5.5 percent annually over 2017-2026, outpacing Gross Domestic Product (GDP) growth by 1 percentage point. The health care share of GDP is estimated to rise from 17.9 percent in 2016 to 19.7 percent in 2026.

Medicare spending is expected to grow 7.4 percent, driven largely by enrollment growth and increased utilization. Medicare spending is projected to grow 8.0 percent on average over 2019-2020, reflecting the incentive payments made to clinicians under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Prescription drug spending is projected to average 6.3 percent annually. The share of the population with health insurance is expected to decrease from 91.1 percent to 89.3 percent in 2026, due in part to the elimination of penalties associated with the ACA’s individual mandate.

As we go to press, special thanks to all of you who took time from your busy schedules to come to Washington and visit your elected members of Congress on Capitol Hill. The groundwork you laid is critical to our success this year and into the future. Please continue to nurture those relationships from your homes. We are available to support you. Thank you for your efforts to assist the entire rehabilitation hospital field.

AMRPA Magazine / April 2018

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CMS Issues Clarification of Medical Necessity of IRH/U Claims: Clarifies Denials Based on Three Hour Rule

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

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

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AMRPA Magazine / April 2018

On February 23, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a new transmittal, revising the Program Integrity Manual (PIM). The changes, which become effective on March 23, 2018, establish a new section of the PIM providing instructions to CMS contractors reviewing inpatient rehabilitation hospital and unit (IRH/U) claims for medical necessity and Medicare coverage. Specifically, the instructions address how contractors review whether an IRH/U stay included an intensive level of rehabilitation therapy services. Under the guidance, CMS instructs its contractors to not deny claims purely on the basis of failure to satisfy the so-called “Three Hour Rule” or other standards related to the amount of therapy provided.

While contractors have long been technically prohibited from using the Three Hour Rule as a benchmark for denying IRH/U claims, this restriction has not always stopped them from denying claims on the basis of failing to provide three hours of therapy per day, five days per week. Contractors have also denied numerous claims for failure to meet the Three Hour Rule when group or concurrent therapy has been used, even though the traditional standard has been that individualized oneon-one therapy must be the “preponderance” of therapy provided in an IRH/U, clearly suggesting that the use of group and/or concurrent therapy is permissible.

The changes to the PIM appear to be aimed at lessening the chances that contractors will summarily deny claims in the future for failure to meet the Three Hour Rule, when further inquiry into the medical necessity of a particular treatment plan is in order.

This further guidance on the Three Hour Rule is long overdue and is consistent with AMRPA’s long-standing position on the intensity of therapy requirement in inpatient rehabilitation hospitals and units. In fact, the prohibition of the use of “rules of thumb” to deny Medicare coverage for IRH/U services goes back decades and was first established by the federal courts in litigation brought by the Center for Medicare Advocacy, led by Judith A. Stein, Executive Director. Stein was recently honored by AMRPA as the recipient of the Chairman’s Award for her longstanding contribution to rehabilitation coverage through years of advocacy on behalf of Medicare beneficiaries.

The new manual section–Section 6.7 of Chapter 6–applies to the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) contractor, Supplemental Medical Review Contractor (SMRC), and Recovery Audit Contractors (RACs). It includes the following key provisions, as set forth in Transmittal 771:

Contractors “shall not make absolute claim denials based solely on a threshold of therapy time not being met,” with such claims instead undergoing “further review.”

“Clinical review judgment” shall be used by the contractors, with decisions “based on the individual facts and circumstances of the case, and not on the basis of any threshold of therapy time.”

“Group and concurrent therapy can be used on a limited basis within the current industry standard” of the Three Hour Rule.

In claims involving group therapy, contractors “shall not deny solely because the situation/rationale that justifies group therapy is not submitted in response to an ADR [additional documentation request].”

Notably, while the new provisions should prevent contractors from denying claims solely on the basis of failure to satisfy

the Three Hour Rule, it will not preclude contractors’ use of the Three Hour Rule to deny claims when other reasons for denial also exist. Taken as a whole, this guidance may signal a move by CMS to remove regulatory barriers that have resulted in a raft of claims denials that are highly subject to challenge, often resulting in decisions

by Administrative Law Judges in favor of IRH/Us.

// The changes to the PIM appear to be aimed at lessening the chances that contractors will summarily deny claims in the future for failure to meet the Three Hour Rule…

This is welcome guidance from CMS that should moderate the often black and white decisions of the Medicare contractors, particularly the CERTS, which are responsible for determining the Medicare error rate for IRH/Us. AMRPA will now work to ensure that the overall message of the new manual guidance—therapy time should not be used as the basis for denying coverage of an IRH/U admission—is not subsumed by any increased restriction on the use of group and concurrent therapy the contractors may issue in the future. It will also be important to monitor how the new guidance affects contractor audits in the coming months now that these provisions are effective.

AMRPA Magazine / April 2018

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Selecting the Impairment Group Code

Lisa Werner, MBA, MS, CCC-SLP

The responsibility for selecting impairment group codes (IGC) and etiologic diagnoses falls on the shoulders of prospective payment system (PPS) coordinators. While there are many nuances and subjective decisions inherent to this position, the final choice for IGCs should be based primarily on the documentation provided in the medical record by the physicians. These codes should reflect the primary conditions for which patients were admitted to inpatient rehabilitation. There are a total of 21 categories to choose from, with more granular choices available within each rehabilitation impairment category (RIC). While it may seem that selecting IGCs should be a clearcut process, there are often patients with highly complicated cases where physicians document the primary reasons for admission in unclear or confusing ways, making final coding decisions far more complicated. This leaves PPS coordinators in the difficult position of having to deconstruct each case and make subjective decisions about which IGC codes are best supported based on myriad factors indicated in each physicians’ documentation. This article will highlight some of the common IGC selection errors I see while auditing charts and provide helpful suggestions and advice on how to make your IRF-PAI coding process easier and more consistently accurate.

Stroke Patients admitted to rehabilitation due to a stroke are most commonly seen after newly diagnosed cerebral vascular accidents. However, this is not always the case.

In some circumstances, patients are brought to inpatient rehabilitation facilities following hospitalization for other conditions that exacerbated their stroke symptoms from a prior event. In well-documented cases, “late effects of a stroke”

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AMRPA Magazine / April 2018

may be used for both a patient’s admission justification and their IGC, although this is often a quagmire for PPS coordinators because of physician documentation. Errors most frequently show up in cases where the reason for admission is stated as “late effects of a stroke” while the remaining documentation focuses on entirely different conditions. If the treatment plan does not indicate that a stroke was the primary factor in determining admission viability, then the IGC should not be stroke. All documentation should follow the same narrative and fully support the chosen IGCs in all cases.

If the patient has neurological manifestations such as foot drop, sensory loss, or neuropathic pain, “Other Neurologic” (03.9) is the best impairment group to use.

Spinal stenosis with neurogenic claudication pairs with IGCs 04.130 or 03.9 based on the clinical presentation of the neurologic involvement. When the physician documentation indicates spinal stenosis without neurogenic claudication, it indicates the absence of spinal cord or nerve root involvement. The most appropriate IGC to use is “Other orthopedic” (08.9). At times, the clinical picture can point to spinal cord involvement while the physician documentation is non-specific. Make sure to assess all clinical documentation, including PT and OT evaluations. Discuss any findings with your physicians to verify that each patient is properly classified. Be sure to assess all of the clinical documentation, including the PT and OT evaluations, and discuss the findings with the physician to ensure that the patient is properly classified.

“Back Pain” (07.2) may be used for patients with severe pain who are closely managed with modality use, frequent monitoring and changing of medications.

“Other Orthopedic” (08.9) is used when a patient has none of the above-mentioned symptoms but still requires rehabilitation before returning home.

I also notice errors when coding aneurysms. Patients with a ruptured aneurysm and active bleeding inside the brain should be coded in the stroke category. If the aneurysm has not ruptured, “non-traumatic brain injury” is the correct IGC. Non-Traumatic Brain Injuries The majority of non-traumatic brain injury etiologic diagnoses can be paired with 02.1. The IRF-PAI Training Manual does not specifically recommend any etiologic diagnoses that pair with 02.9, which leads me to believe that 02.9 should only be used in unusual circumstances.

Incidentally, IGC 02.1 is 60% rule compliant, but IGC 02.9 is not. When I review data in eRehabData®, I tend to see IGC 02.9 paired with diagnoses that would have been just as, if not more, correct if IGC 02.1 were used instead.

Also, remember that a subdural hematoma should be coded as a non-traumatic brain injury because the bleeding is not within the dura.

Quadriplegia and Paraplegia When you use IGCs 04.110-04.1222 and 04.21004.2222, the diagnosis code should reflect the injury that caused the paraplegia/quadriplegia. I often see quadriplegia and paraplegia ICD-10 diagnosis codes paired with the equivalent impairment groups, but I recommend against coding these etiologic diagnoses and impairment groups with redundant codes.

Make sure that your etiologic diagnoses indicate complete or incomplete spinal cord injuries when using the IGCs that indicate either complete or incomplete quadriplegia/ paraplegia. If you don’t know whether the injuries are complete or incomplete, use the IGC for unspecified quadriplegia/paraplegia. While the use of unspecified codes is not recommended, they may be necessary in isolated cases.

Spinal Stenosis Remember your options when identifying the correct impairment groups for use with lumbar laminectomy or spinal stenosis diagnoses.

The “Other Non-Traumatic Spinal Cord Dysfunction” code (04.130) indicates that the spinal stenosis has caused spinal cord involvement affecting the lower extremities, bowel/bladder function, and/or sensation.

Neurological In the neurologic rehabilitation impairment categories, there are options for specific impairment groups such as multiple sclerosis, polyneuropathy and neuromuscular disorders. There is also a “non-specific” category that should only be used in the absence of a more specific impairment group. If a patient has myopathy, it may be better to select IGC 03.8, “Neuromuscular Disorders”. If a patient has encephalopathy, use 02.1, “Non-Traumatic Brain Injury.” If a patient has polyneuropathy, use 03.3. I regularly see 3.9 used for the conditions stated above, which results in lost opportunities for 60% rule compliance.

Pain The use of any IGC in the 7.x series indicates that the pain condition is more prominent than any other condition.

Notes supporting these IGCs should state how the pain was managed and include modality use, frequency of changes to medications, close monitoring of pain, and pain management. ICD-10 codes like M79.604, “Pain in right leg,” are redundant in combination with pain IGCs. When using pain IGCs, the etiologic diagnosis should define either the source or the cause of the pain.

Major Multiple Fractures Use of IGC 08.4, “Status Post Major Multiple Fractures” indicates that the patient has fractures in two or more weight-bearing bones. One of these fractures must be in the lower extremities. If you choose to use the primary fracture as the etiologic diagnosis, make sure to include at least one other fracture in a weight-

AMRPA Magazine / April 2018

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bearing bone as a comorbidity. A combination code that represents the combined presence of upper/lower limb fractures, or tibia/fibula fractures, does not exist.

Amputations The IGC 05.9, “Other Amputation” cross-walks to RIC 11, “Amputation, non-lower extremity.” This IGC should not be used if the patient’s amputation involved a lower extremity.

Pulmonary Conditions – Chronic vs. Acute The pulmonary IGCs 10.1 and 10.9 are designated for chronic pulmonary conditions. Acute conditions (for example, J18.9, “Pneumonia”) should be coded under IGC 16, “Debility.”

Major Multiple Trauma IGC 14.9, “Other Multiple Trauma” should be used when the patient presents with two or more injuries to systems/sites other than the brain or the spine. One of these injuries can be a traumatic fracture. If brain injuries or spinal cord injuries are present, the impairment group would change to either 14.2 or 14.3 respectively. If both a brain injury and a spinal cord injury are present, the impairment group would be 14.1.

When coding major multiple trauma with brain and/or spinal cord injury, it is most appropriate to code the specific condition. Always code the etiologic diagnosis as the cause of the brain injury when using 14.2, and code the cause of the spinal cord injury with 14.3.

Debility Rather than a general code, the impairment group “Debility” should be supported by an ICD-10 code that describes the patient’s medical impairment. Avoid using R53.81, “Other malaise,” R53.1, “Weakness,” or M62.81, “Muscle weakness” even though the IRF-PAI Training Manual pairs codes like these with IGC 16, “Debility.”

Consider all other available impairment group options before selecting IGC 16, “Debility.” I’ve seen numerous examples of IGC 16 being chosen when a more relevant IGC exists. Refer to the IGC Distribution by Diagnosis table on the Medical tab in your eRehabData® patient assessment for information about how other providers have coded patients with the same etiologic diagnosis.

17.x Series Impairment Group Codes The 17.x series of IGCs should rarely be used. These codes are reserved for when a patient is admitted to rehab

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and the therapy program is secondary to managing a medical condition. Since this is rarely the case with rehab admissions, most patients currently coded in the 17 series are more appropriately classified with IGC 16, “Debility.”

// While it may seem that selecting IGCs should be a clear-cut process, there are often patients with highly complicated cases where physicians document the primary reasons for admission in unclear or confusing ways…

In conclusion, PPS coordinators have a substantial responsibility for selecting the correct IGCs. Because these codes are key elements in determining facility reimbursements, they must be correct. Make sure to clarify situations where the correct IGC isn’t readily apparent with the physicians themselves. Physicians should be open to these questions and willing to participate in an open dialogue for each inquiry. These interactions should consist of more than the physician telling the PPS Coordinator what to write. The best practice is to discuss each patient’s presentation and cooperatively determine which IGCs are the most accurate.

Some providers ask the physician to assign an IGC within their H&P. While I whole-heartedly trust doctors to take care of medical needs, I have less trust in their coding skills (a sentiment I think most physicians would agree with). To ensure correct coding, it really does “take a village.” PPS coordinators shoulder the responsibility of making sure these codes are correct. To accurately and successfully do this, coordinators should double-check with physicians and any other staff who may help to inform a correct decision, all while using their extensive training and knowledge to make sure that IGCs conform with all documentation.

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LEARN MORE & JOIN TODAY www.thefairfund.org We are the Fund for Access to Inpatient Rehabilitation, a Common Legal Defense Fund Composed of America’s Top Inpatient Rehabilitation Hospitals and Units.

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For more information, or to speak with a FAIR Fund leader or staff member, contact Rebecca Schnorf at rschnorf@firminc.com or at (217) 321-2477.

Administration Announces New Programs to Help Beneficiaries Access Their Health Care Data

On March 6, the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announced a new health care data initiative as part of one of the priority emphases set forth by the Secretary of the Department of Health and Human Services (HHS) Alex Azar the day before.

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

Highlight: »»

CMS’ MyHealthEData initiative seeks to expand patient access to electronic health data and update provider requirements for using certified electronic health record technology and sharing of patient data.

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Administrator Verma said that, in CMS’ commitment to put patients first, it seeks to approach issues with health care data from patients’ perspective. The effort intends to move to a system in which patients will have more control of their health care information in order to empower them to make informed decisions about their health and care. The administration believes that by ensuring patients have access to their full health care records and can take them with them from doctor to doctor, provider to provider, may increase competition and reduce costs.

Last year, President Trump issued an Executive Order to Promote Health Care Choice and Competition across the United States. The president wants his administration to prioritize fostering competition in health care markets, so patients may receive higher-value care. Rehabilitation providers may be interested in the section below on discharge information and what information referring providers, primarily acute hospitals, will need to provide to a post-acute care provider to which the patient is referred.

Expanding Patients Access and Control of Their Data In a press release accompanying the announcement, CMS states that currently patients do not have full control of their own health care information and cannot easily take their data with them as they move in and out of

the health care system and receive services. This data includes essential records, test results and basic information about the providers who treat them.

Payment Program (QPP) for clinicians (part of MACRA) to increase the programs’ focus on interoperability and to reduce the time and cost required to comply with them.

MyHealthEData Initiative The administration launched the MyHealthEData initiative, which aims to empower patients by ensuring that they control their health care data and can decide how their data can be used in a secure manner. The overall government-wide initiative will be led by the White House Office of American Innovation with participation from HHS–including CMS, the Office of the National Coordinator for Health Information Technology (ONC), and National Institutes of Health (NIH)– as well as the U.S. Department of Veterans Affairs (VA).

CMS intends to prioritize the use of quality measures and improvement activities in value-based care and quality programs that lead to interoperability. CMS also intends to take steps against information blocking (a practice in which providers prevent patients from getting their data), as required by law, by requiring hospitals and clinicians under some CMS programs to show they have not engaged in data blocking activities.

Medicare’s Blue Button 2.0 CMS is launching Medicare’s Blue Button 2.0, which seeks to improve the Medicare beneficiary experience by providing them with their claims data in a universal and secure digital format. Medicare first launched Blue Button in 2010 to give patients access to their claims data in a downloadable PDF file. Now, with Blue Button 2.0, beneficiaries will be able to take their data and use it on applications designed to help them manage their health or share it with their doctors.

Medicare’s Blue Button 2.0 contains four years of Medicare Part A, B and D data for 53 million Medicare beneficiaries and provides multiple types of information including prescriptions and primary care treatments. CMS has recruited more than 100 organizations to join CMS’ Medicare Blue Button 2.0 developer preview program. It expects more to sign on as Medicare’s Blue Button 2.0 is launched to Medicare beneficiaries. The developer preview program allows application developers to build and test apps to connect to Blue Button 2.0 using test claims data. Medicare’s hopes that its changes to the Blue Button service will enable beneficiaries to give their physicians access to information on their current prescriptions and medical history, to save time during appointments and improve the quality of care delivered.

CMS will be re-examining its expectations for Medicare Advantage (MA) plans and qualified health plans (QHPs) offered through the federally facilitated exchanges, and calling on all health insurers to release their data. CMS believes that the private plans that contract through Medicare Advantage and the exchanges should provide the same benefit that is being provided through Medicare’s Blue Button 2.0.

Encouraging Patient Access through CMS Programs With respect to other technology, CMS seeks to overhaul CMS’s Electronic Health Record (EHR) Incentive Programs to save time and costs. This includes streamlining the Medicare and Medicaid EHR Incentive Programs for eligible hospitals and critical access hospitals (commonly referred to as the Meaningful Use programs) and the Quality

Modernizing Provider Requirements with a Focus on Value-based Care The administration states that it is committed to moving away from fee-for-service and toward a system that pays for value. CMS will support requirements that focus on achieving interoperability and secure information exchange because they are critical to the success of new value-based payment models. All of the providers in a patient’s network will need to coordinate their care for a value-based system to work.

Certified EHR Technology As part of the effort to ensure that data follows the patient, CMS finalized for some of its programs the requirement for health care providers to use 2015 Edition certified EHR technology (CEHRT) beginning in 2019, which is capable of giving data to patients in a usable and secure electronic format. The updated 2015 Edition CEHRT includes technical requirements focused on interoperability and the ability of patients and their care teams to share health care data more effectively through application programming interfaces (APIs). APIs are software that allow other software to connect to one another and are the primary way that data is shared electronically.

In an effort to ensure that health care data follows the patient, CMS intends to specify what types of information–ideally in electronic format–must be shared by hospitals with patient’s receiving care from a post-acute care provider. In its efforts to help clinicians spend time on patient care instead of documentation, CMS is considering stakeholder feedback and looking into streamlining its policies around documentation guidelines for Evaluation and Management (E&M) codes (the codes that doctors use to bill Medicare for patient visits) to modernize documentation requirements and reduce clinician burden. Provider systems typically do not share patients’ data, which can lead to duplicate tests when a patient goes to see a different provider. This increases costs and can lead to patient inconvenience or even harm. CMS is studying the extent and impact of duplicate testing, and will identify ways to reduce the incidence of unnecessary duplicate testing.

For the announcement, see the CMS website.

AMRPA Magazine / April 2018 13

MedPAC Turns to Developing Accurate Payments for Sequential Stays in Post-Acute Care

At its March 1 public meeting, the Medicare Payment Advisory Commission (MedPAC) held a session titled, “Paying for Sequential Stays in a Unified Payment System for Post-acute Care.” MedPAC first introduced this topic at its October 2017 meeting, and it appears to be the Commission’s focal point this year as it continues to explore implementation issues for its unified post-acute care prospective payment system (PAC PPS) proposal.

Mimi Zhang, Senior Policy and Research Analyst, AMRPA

Highlights: »»

Of 8.9 million post-acute care (PAC) stays in 2013, about 20 percent were for back-to-back, or sequential, stays.

»»

Sequential stays present challenges to payment accuracy under a unified PAC payment system, according to MedPAC.

14 AMRPA Magazine / April 2018

Under a unified PAC PPS, provider payments would be based on the average cost of an episode, or stay, and adjusted using beneficiary and stay characteristics.

According to MedPAC’s research, about half of PAC stays are sequential stays (i.e., the second or third site of PAC), and the vast majority of sequential stays are transitions from higher intensity to lower intensity settings. Because the cost of care is likely to decline over a patient’s continuum of care, the Commission believes that a downward payment adjustment is needed for sequential PAC stays.

As an example, a spinal cord injury patient may be first admitted to an inpatient rehabilitation facility (IRF) for acute medical rehabilitation and then discharged to a skilled nursing facility (SNF) for ongoing therapy. Because the patient has most likely gained functional ability during their IRF stay, their subsequent SNF stay would be less intensive and costly, and therefore warrant a lower payment rate.

However, in MedPAC’s PAC PPS model, these IRF and SNF stays would have similar payments because the underlying patient characteristics would remain the same.

Functional Status Data It must be noted that MedPAC’s model of the unified PAC PPS, in its original design, does not include functional status. Functional ability would not be an underlying patient characteristic and hence would not be a payment adjustor for a PAC stay or episode. The Commission asserts that its unified payment model could accurately predict costs (and payments) without the functional status data collected across PAC settings pursuant the IMPACT Act. In 2016, MedPAC recommended to Congress that a PAC PPS could be implemented

before IMPACT Act data collection is complete and that the functional data could be incorporated at a later date.

It begs the question that if MedPAC's PAC PPS proposal accounts for patient function in setting payment rates, would sequential stay payment adjustments still be needed since improved patient function would trigger lower payments at each sequential setting.

Analysis of Claims Data Of the 8.9 million PAC stays in 2013, MedPAC found 1.9 million stays included multi-stay sequences, half of which were “lateral stays” in which a beneficiary had back-to back-stays in the same setting. MedPAC staff presented the graph below illustrating the 15 most frequent PAC utilization pathways in 2013. There were more than 5,700 different combinations, 36 percent of which are multi-stay sequences.

Of those, the top 10 pathways make up three-quarters of all multi-sequence stays, 50 percent are lateral stays, 33 percent of stays transition to settings of lower intensity, and ten percent are transitions to higher intensity settings.

A solo IRF episode was the seventh most common PAC stay, and a sequence of an IRF stay followed by SNF stay was the ninth most common. Solo home health stays made up almost 2.5 million PAC stays, and multiple back-to-back home health stays made up five of the top 15 most frequent PAC stay sequences. The most common sequences of decreasing intensity include a SNF stay followed by a home health stay, and an IRF stay followed by a home health stay.

Most frequent solo and sequences of PAC stays (2013)

Source: MedPAC Compared with solo home health stays, sequential home health stays are more likely to feature dual eligible beneficiaries, disabled patients and admissions from the community. Less medically complex beneficiaries are also reportedly more likely to be served by for-profit

and freestanding home health agencies. In contrast, institutional PAC stays (IRF, SNF or long-term care hospital) in sequences are less likely to feature dual eligible, disabled beneficiaries and community admissions than solo institutional stays. According to MedPAC, beneficiaries with sequential institutional stays were more likely to be medically complex, and these providers were more likely to be nonprofit and hospital-based providers.

For home health stays, in particular, data show that costs are lower for later stays in a sequence. Without an adjustment, profitability under a PAC PPS would be higher for later home health stays. Staff suggest that while a PAC PPS would establish accurate payments for most stays, payments for later home health stays may need to be adjusted.

Treating in Place Another issue MedPAC discussed is how to differentiate stays when an institutional PAC provider treats a patient “in place” instead of discharging to a lower intensity setting and thereby triggering another PAC admission. This approach could become a more common practice under the unified PAC PPS because PAC regulations would become aligned and enable providers more flexibility to treat patients over a continuum of care. MedPAC staff views treated in place stays as sequential institutional PAC stays because they involve different levels of care and, accordingly, need a way to identify a stay “trigger” for each phase of care in a way that does not induce unnecessary volume.

MedPAC proposes that the separate stays could be defined using length of stay and a provider would receive a unified PAC PPS payment for the initial stay. Stays that reach a certain length of stay (e.g., 30 days) trigger a new assessment and a separate payment. While this approach would be easy to define, administer and monitor, it does carry an incentive to inappropriately extend stays beyond the threshold to generate additional payments. MedPAC is evaluating policies to counterbalance these incentives, including:

Defining a length of stay using a long duration so that most stays are encompassed by it and partnering it with a short-stay outlier policy

Require physician attestation of continued need for care

Implement value-based purchasing that includes a resource use measure

Audit providers with aberrant lengths of stay and high use of subsequent PAC stays

Next Steps During the ensuing discussion session, several commissioners commented on the similarity between the issues in PAC sequential stay payments and bundled payments. As such, Commission Chair Dr. Francis J. Crosson asked the staff to additionally explore whether there are solutions or strategies present in bundled payment models that apply to setting payment rates for sequential PAC stays.

AMRPA Magazine / April 2018 15

New Outpatient Therapy Billing Procedures Now in Effect

As AMRPA previously reported, the Bipartisan Budget Act of 2018, which was signed in to law on February 9, repealed the hard cap on Medicare outpatient therapy services. The Centers for Medicare and Medicaid Services (CMS) has now issued guidance on this new law, which is consistent with AMRPA's previous analysis provided to members and is summarized below. AMRPA actively participated in the successful effort for a permanent repeal of the therapy caps, along with other stakeholders involved in the Therapy Caps Coalition.

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

Highlights: »»

KX Modifier must continue to be used at $2,010 threshold.

»»

Claims now subject to targeted medical review at $3,000 threshold.

16 AMRPA Magazine / April 2018

The new law dictates that the hard cap on therapy services is repealed retroactively to December 31, 2017. Claims for therapy services above a certain threshold will still require the use of the KX modifier. The use of the KX modifier serves as an attestation that the services are medically necessary and justified by appropriate medical record documentation. For 2018, the threshold for the KX modifier will be $2,010, and that number may rise with inflation in future years.

Further, the use of this threshold will continue to be applied as two separately accumulated thresholds, one for physical therapy and speech-language therapy services combined, and one for occupational therapy services.

Previously, all claims above $3,700 per beneficiary were subject to targeted medical reviews. With this new legislation, the threshold for targeted medical review of claims has been lowered to $3,000. This $3,000 threshold will remain intact until 2028 when it will be adjusted for inflation. While there is now a lower threshold, the legislation also directed that only $5 million be given to the U.S. Department of Health and Human Services (HHS) to conduct these reviews, which is the same amount provided previously, so no increase in the number of reviews conducted is expected.

As is the case with the KX modifier threshold, the $3,000 threshold for targeted medical reviews will be applied as two separate thresholds; one for physical therapy and speech-language pathology services, and one for occupational therapy services. Additionally, the law retained the same factors that HHS may use when determining which claims to target for medical review.

These factors are:

The therapy provider has a high claims-denial percentage for therapy services or is less compliant with other Medicare requirements.

The therapy provider has a pattern of billing for Medicare therapy services that are aberrant compared to peers or otherwise has questionable billing practices for such services, such as billing medically unlikely units of services in a day.

The therapy provider is newly enrolled under Medicare or has not previously furnished therapy services under Medicare.

The services are furnished to treat a type of medical condition.

The therapy provider is part of group that includes another therapy provider identified as fitting one of the previous descriptions.

Finally, the new outpatient therapy billing procedures will apply to services delivered in all settings, including hospital outpatient departments. CMS states in its guidance that it will begin releasing claims that had been held due to the temporary lapse in the therapy caps exception process on a first-in, first-out basis, until no claims are being held. CMS does not give an estimate for when it will complete releasing all held claims.

AMRPA will continue to monitor future guidance from CMS on the implementation of these new policies.

If you have any concerns or issues with outpatient services, contact AMRPA Regulatory and Government Relations Counsel Jonathan Gold at JGold@amrpa.org.

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Early Bird Exhibitor Rate Ends on June 30, 2018 Regular Exhibitor Rate Begins on July 1, 2018 Tiered sponsorship packages available!

Visit www.amrpa.org to view the sponsorship and exhibitor prospectus and get involved today.

AMRPA Magazine / April 2018 17

AMPRA Spring Conference & Congressional Fly-In 2018

Richard Kathrins, PhD, AMRPA Board Chair and President & CEO, Bacharach Institute for Rehabilitation, kicks off the 2018 Leadership Forum.

On March 11-13, 2018, AMRPA held its largest Spring Conference & Congressional Fly-In ever at the Embassy Row Hotel in Washington, DC, with a 53 percent increase in attendance from its 2017 Spring Conference. Attendees heard updates directly from industry officials such as David J. Shulkin, MD, Secretary, Department of Veterans Affairs, James Mathews, PhD, Executive Director, Medicare Payment Advisory Commission (MedPAC), Joe Grogan, Associate Director for Health Program at the Office of Management, Executive Office of the President, and many more. AMRPA’s next conference will be the Fall Educational Conference & Expo, September 24-26, in Boston. Visit amrpa.org to learn more and to submit your abstract for consideration.

Watch for a detailed summary of this conference in the May issue of AMRPA magazine.

Department of Veterans Affairs Secretary David J. Shulkin, MD, discusses expanding access to care for Veterans at the AMRPA Spring Conference & Congressional Fly-In.

18 AMRPA Magazine / April 2018

CALL FOR ABSTRACTS & POSTERS Visit us at amrpa.org to submit your abstract!

Deadline for submission is: April 16, 2018

PRESENT

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

NETWORK

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

BUILD YOUR CV

Add AMRPA’s name to your CV and learn new skills along the way.

TRACKS:

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

AMRPA Magazine / April 2018 19

Even Experienced Wheelchair Users Can Benefit from New Techniques to Reduce Upper Body Stress, Study Says Highlight: 

Web-based training may be an efficient way to give wheelchair users information about proper transfer techniques and reduce risk of injury or chronic pain in wrists, arms and shoulders.

Researchers from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) conducted a study to compare the effectiveness of an in-person and a web-based training module to teach wheelchair users about proper transfer techniques and findings were published by the National Rehabilitation Information Center (NARIC) Research In Focus.

The study states that persons who use wheelchairs for daily mobility may transfer in and out of their wheelchair up to 20 times per day and these frequent transfers can put stress on a person’s upper body over time. Previous research has shown that improper transfer techniques, such as placing the wheelchair at the wrong angle or not removing or dropping armrests, can lead to wrist or shoulder injuries and pain. Training on proper transfer techniques may help wheelchair users reduce those injuries. Such training can take place in a physical therapy clinic or rehabilitation center or offered online.

The researchers sought to determine if the web-based training was as effective as the in-person training for improving transfer skills, and whether both training formats improved those skills when compared to no training.

They also wanted to find out who benefited most from transfer training.

Study Participants Researchers on the Translating Transfer Training and Wheelchair Maintenance into Practice project and the University of Pittsburgh Model Center on Spinal Cord Injury enrolled 71 wheelchair users in the study.

The participants were athletes competing in wheelchair sporting events for veterans with disabilities. All of the participants could transfer independently but did not use their legs to assist in transferring. The participants were randomly assigned to one of three groups: 1. 10 participants were assigned to an in-person training group 2. 39 participants were assigned to a web-based training group 3. 22 participants were assigned to a comparison group that was evaluated but received no training The participants in the in-person training group had an hour-long individual session with a physical therapist. The physical therapist demonstrated proper transfer techniques, gave the participants feedback on their current transfer techniques, and suggested improvements to reduce strain on their upper body.

The participants had a chance to practice improved techniques with feedback from the therapist during the training session. The participants in the web-based

20 AMRPA Magazine / April 2018

training group were presented with an online module that took them about an hour to complete.

The module consisted of four main components: 1. Information about how improper transfers can cause wrist and shoulder problems 2. A description of the three phases of a transfer 3. Ways to make transfers easier on the wrists and shoulders 4. Information about how to adapt transfer techniques to more complicated transfers, such as transferring to the car or toilet seat The participants in the comparison group received no training or information on transfer techniques, either in person or via the web.

Before the study began, all of the participants answered basic questions, such as their age, their type of disability, and how long they had been a wheelchair user. Then, all of the participants were evaluated by a trained researcher who observed them as they transferred into and out of their wheelchair. The participants in both training groups were evaluated three times: once before training, once right after training, and once one to two days after training, to see how long their new skills lasted. The participants in the no-training comparison group were evaluated twice, once when they enrolled in the study and again one to two days later. During the evaluation, the trained observer rated how many of 14 proper transfer techniques the participant used. For example, they observed whether the participant moved the armrest out of the way before transferring; whether the transfer angle was between 20 and 45 degrees; or whether the movement was smooth and well-coordinated.

Findings The researchers found that the participants in both training groups improved their transfer techniques after the training compared with their techniques before the training.

Participants in the in-person training group improved by an average of 14 percent.

Participants in the web-based training group improved by an average of 29 percent.

In addition to the immediate improvement after the training, these improvements were maintained one to two days after the training. When the researchers looked at who improved most after training, they found that the participants with lower technique scores before training improved more than the participants with higher scores, regardless of whether they had in-person training or web-based training. The participants with multiple sclerosis, amputations or other disabilities

improved more than the participants with spinal cord injury.

However, the participants’ age or how long they had been a wheelchair user was unrelated to their level of improvement.

The authors noted that all of the participants in the study were athletes, and it is possible that a less athletic sample of wheelchair users might show different results. They also noted that the in-person group consisted only of individuals with paraplegia and their initial technique scores were higher than the more diverse web-based group. This may help to explain less improvement seen in the in-person group based on the earlier finding that participants with higher initial scores showed less improvement than those with lower scores. Based on the results of this study, the authors also noted that even experienced, athletic individuals may be able to improve their transfer technique through training. Participants in this study even reported learning some techniques for the first time.

// The researchers found that the participants in both training groups improved their transfer techniques after the training compared with their techniques before the training.

According to the authors, web-based training may be an efficient way to give wheelchair users information about proper transfer techniques and therefore reduce risk of injury or chronic pain in wrists, arms, and shoulders. web-based information may be especially helpful for people who live far away from a clinic. The training can be beneficial regardless of age or level of experience using a wheelchair. Future research may be useful to evaluate the effectiveness of web-based training with a broader sample, and to develop open-access materials for wheelchair users to practice their transfer skills on their own.

For more information about the study, see the NAIRC website.

AMRPA Magazine / April 2018 21

GAO Examines Medicaid Demonstration Evaluations, Says Improvements are Needed

Highlight: »»

GAO found that selected states’ evaluations of these demonstrations often had significant limitations that affected their usefulness in informing policy decisions.

Medicaid demonstration projects represent roughly a third of the more than $300 billion in federal Medicaid spending in 2015 and are a powerful tool to test new approaches to providing coverage and delivering Medicaid services that could reduce costs and improve beneficiaries’ outcomes. Evaluations are essential to determining whether demonstrations are having their intended effects.

A recent report released by the Government Accountability Office (GAO), “Medicaid Demonstrations – Evaluations Yielded Limited Results, Underscoring Need for Changes to Federal Policies and Procedures,” examined state-led evaluations and federal evaluations and highlights from the report are provided below.

Study Purpose Under Section 1115 of the Social Security Act (SSA), the Secretary of Health and Human Services (HHS) may approve Medicaid demonstrations to allow states to test new approaches to providing coverage and for delivering services that can transform large portions of states’ programs. States are required to evaluate their demonstrations and the Centers for Medicare and Medicaid Services (CMS) can conduct its own federal evaluations.

22 AMRPA Magazine / April 2018

Examples of Gaps in States’ Evaluations of Medicaid Section 1115 Demonstrations Arizona The state was required to evaluate whether providing long-term services and supports under a managed care delivery model improved access and quality of care. The evaluation report lacked information on important measures of access and quality.

Arkansas

Massachusetts

The state was required to evaluate the effects of using Medicaid funds to purchase private insurance for more than 200,000 beneficiaries.

The evaluation did not address a key hypothesis that using private insurance would improve continuity of coverage for these beneficiaries, who were expected to have frequent changes in income that could lead to coverage gaps.

The state was required to evaluate the effectiveness of its approach of providing up to $690 million in incentive payments to seven hospitals to improve quality of care and reduce per capita costs. Evaluation reports submitted after five years provided no conclusions on the impact of the payments in these areas.

Source: GAO. | GAO-18-220

GAO was asked to examine these evaluations, including how the results have been used to inform Medicaid policy.

GAO reviewed evaluation documentation for eight states with high demonstration expenditures that varied in the number of years their demonstrations had been in effect and by geography. GAO also reviewed documentation for the ongoing federal evaluations and interviewed state and federal Medicaid officials. GAO assessed evaluation practices against federal standards for internal control and leading evaluation guidelines.

GAO Findings

Some states’ evaluations of these demonstrations often had significant limitations that affected their usefulness in informing policy decisions. The limitations included gaps in reported evaluation results for important parts of the demonstrations. These gaps resulted, in part, from CMS requiring final, comprehensive evaluation reports after the expiration of the demonstrations rather than at the end of each three- to five-year demonstration cycle.

CMS has taken a number of steps since 2014 to improve the quality of state-led evaluations, however, the agency has not established written procedures for implementing such requirements, which could allow for gaps to continue.

In October 2017, officials stated that the agency planned to require final reports at the end of each demonstration cycle for all demonstrations. CMS also plans to allow states to conduct less rigorous evaluations for certain types of demonstrations but has not established criteria defining under what conditions limited evaluations would be allowed.

Federal evaluations led by CMS have also been limited due to data challenges that have affected the progress and scope of the work. For example, delays obtaining data directly from states, among other things, led CMS to considerably reduce the scope of a large, multi-state evaluation, which was initiated in 2014 to examine the impact of state demonstrations in four policy areas deemed to be federal priorities. Though CMS has made progress in obtaining needed data, it is uncertain when results from the multi-state and other federal evaluations will be available to policymakers because CMS has no policy for making results public. By not making these results public in a timely manner, the agency says that CMS is missing an opportunity to inform important federal and state policy discussions.

GAO’s Recommendations GAO recommends that CMS: 1) establish written procedures for requiring final evaluation reports at the end of each demonstration cycle; 2) issue criteria for when it will allow limited evaluations of demonstrations including defining conditions, such as what it means for a demonstration to be longstanding or noncomplex, as applicable; and 3) establish a policy for publicly releasing findings from federal evaluations of demonstrations. HHS concurred with these recommendations.

The complete report is available on the GAO website.

The report states that the federal government did not require complete and timely evaluations from the states, so conclusive results were not available. Moreover, the federal government wasn't making its evaluation results public— missing opportunities to inform federal and state Medicaid policy discussions.

AMRPA Magazine / April 2018 23

Medicare Spending on Health Services Closely Linked to How Care is Delivered, Commonwealth Study Says

Highlights: »»

»»

Increased prevalence of some diseases has driven up perbeneficiary costs for Medicare, but large reductions in spending for some chronic conditions have offset this.

To further lower per-beneficiary Medicare spending, it may be just as important to improve the efficiency of care delivery as it is to prevent disease.

24 AMRPA Magazine / April 2018

The average amount that Medicare spent on health services for each beneficiary age 65 and older declined by $180 between 2007–2010 and 2011–2014, according to a recent study published in the Commonwealth Fund Literature Review, Understanding Trends in Medicare Spending, 2007–2014. Given the historically low growth in provider spending in recent years, a better understanding of the factors contributing to Medicare spending growth will enable health care policymakers to better set improvement priorities and targets.

Most of the decrease was attributed to lower spending for Medicare beneficiaries with certain chronic illnesses, particularly cardiovascular and endocrine conditions — possibly a result of efforts by health care stakeholders to control costs and improve efficiency. However, the rising prevalence of chronic kidney disease and certain other conditions reduced overall savings for Medicare.

Prior studies have shown that chronic disease prevalence and population characteristics contribute less to changes in Medicare spending per beneficiary

(MSPB) than the volume and type of health services provided.

The Commonwealth Fund-supported researchers sought to determine if this finding has remained true for recent Medicare spending on hospital, post-acute and physician services, which have been growing at historically low rates.

An improved understanding about the significant cost drivers in health care spending growth will allow all stakeholders to develop more targeted cost saving interventions. For example, if spending growth is primarily stemming from rising diabetes rates, then a heightened focus on diabetes prevention would be warranted. Alternatively, if diabetesrelated spending per beneficiary is rising significantly, then improvements may be needed in how care is delivered to patients.

The researchers compared spending on Medicare Parts A and B services, which include inpatient, outpatient and post-acute care, for a 5 percent sample of Medicare fee-for-service (FFS) enrollees aged 65 and older between 2007–2010 and 2011– 2014, the latter period a time when per-beneficiary Medicare spending growth slowed. Annual per-beneficiary spending was obtained from the Master Beneficiary Summary File and all spending was adjusted to 2007 payment levels.

Key Findings

The higher prevalence of many diseases increased perperson Medicare spending by $125 between 2007–2010 and 2011–2014. However, large decreases in spending for some chronic conditions offset these population changes. For instance, while there was a large increase in the proportion of enrollees with chronic kidney disease, overall spending for this condition decreased by enough to lower per-beneficiary spending by nearly $28.

Cardiovascular disease spending saw the largest reductions, decreasing by nearly $192 per beneficiary due to declines in both disease prevalence and spending. The proportion of enrollees with cardiovascular disease decreased from 38 percent to 35 percent between the two periods. At the same time, spending declined for nearly all types of heart conditions, except heart failure.

joint conditions, as well as Alzheimer’s disease or dementia, was linked to spending increases as opposed to disease prevalence.

They found that Parts A and B spending increased among beneficiaries who had Part D or any other type of prescription drug coverage.

// … the decrease in per-beneficiary Medicare spending may reflect a shift toward value-based approaches to delivering and paying for health care services…

The study authors state that the decrease in per-beneficiary Medicare spending may reflect a shift toward value-based approaches to delivering and paying for health care services.

The Centers for Medicare and Medicaid Services (CMS) launched a number of value-based initiatives before and during the study periods. For example, lower spending on chronic kidney disease may be partly a result of Medicare’s new bundled payment program for dialysis, which launched in 2011.

While the study did not examine the impact of CMS’s value-based initiatives, the findings suggest that these programs and other efforts to change care delivery may have contributed to lower spending. To further lower perbeneficiary Medicare spending, it may be just as important to improve the efficiency of care delivery as it is to prevent disease.

For more information about the study, see the Commonwealth Fund In the Literature website.

Some chronic conditions saw increases in per-beneficiary spending. A rising number of older persons with diagnosed depression led to an increase in spending for that condition. In contrast, a rise in spending for skeletal and

AMRPA Magazine / April 2018 25

NQF’s Measure Applications Partnership Recommends Measures for Federal Health Care Programs Highlight: »»

MAP recognizes need to refine the IRF QRP’s infection measures given the low incidence of infection in inpatient rehabilitation hospitals or units.

The National Quality Forum’s (NQF) Measure Applications Partnership (MAP) submitted recommendations to the Department of Health and Human Services (HHS) for 35 standardized performance measures under consideration for use in federal health care programs.

NQF has convened MAP annually since 2010 and consists of more than 200 health care leaders and experts from more than 110 private- and public-sector organizations to provide recommendations on the highest-impact measures that will improve health and health care for Medicare beneficiaries.

Measure Applications Partnership (MAP) The MAP Coordinating Committee and its hospital, clinician, post-acute and long-term care workgroups, with input from its rural workgroup, identify measurement gaps across settings, prioritize high-impact measures, and recommend alignment of measures across federal programs that affect 58 million Americans enrolled in Medicare and their health care providers.

MAP volunteers represent consumers, purchasers, employers, health plans, clinicians and providers, communities and states, suppliers, and federal agency liaisons. MAP conveyed varying degrees of support for all but one of the 35 measures under consideration, a measure of lumbar spine imaging that HHS is considering for the Hospital Outpatient Quality Reporting (OQR) program. MAP did not support this measure because it is no longer NQF-endorsed.

MAP relies on NQF endorsement to ensure that a measure reflects high-quality, evidencebased care and provides consistent and accurate information about provider performance.

As AMRPA reported previously, the MAP did not review potential new measures for the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) in the federal fiscal year (FY) 2019 rulemaking cycle. Regarding the IRF QRP, the MAP did discuss what it views as measure gaps in the measure set, such as the need for measures addressing the transfer of patient information. MAP additionally identified the need for measures addressing appropriate clinical uses of opioids in inpatient rehabilitation hospitals or units (IRH/Us). Finally, MAP highlighted the need for refinements to the infection measures currently included in the measure set as an additional gap given the low incidence of infection in IRH/Us, an issue that AMRPA has raised with the Centers for Medicare and Medicaid Services (CMS) as well.

Overall, MAP supported six measures and conditionally supported 25 measures (a designation most commonly made to note support of a measure pending NQF endorsement). MAP recommended refinements to three measures, reflecting support of the measure concepts with a need for further testing or potential changes to the measures to ensure that they are scientifically sound. One of these measures is intended to help address the growing opioid epidemic by assessing continuous pharmacotherapy for opioid use disorder. Prior to the measure’s use in the Merit-based Incentive Payment System (MIPS), MAP recommended that the measure be tested and evaluated for NQF endorsement to ensure that it accurately assesses physician and practice-level performance. The measure is currently endorsed for use by health plans and states.

NQF published its final reports for hospital and post-acute settings on February 15 and its report for clinician programs on March 15. Both reports include recommendations on potential ways to improve the programs and the measures used in them, including guidance on criteria for HHS when considering which measures to remove from federal programs and potential areas for future measures.

For more information, see the NQF website.

26 AMRPA Magazine / April 2018

AMRPA Sends Letter to CMS on Access and Transparency Issues in the Medicare Advantage Program Editor’s Note: On March 2, 2018, AMRPA submitted a letter to the Centers for Medicare and Medicaid Services (CMS) responding to proposed updates to the Medicare Advantage (MA), Part C and Part D programs through the 2019 Advance Notice and Draft Call Letter. This article features AMRPA’s comments in an abbreviated and edited form. The full comments are available for members at www.amrpa.org On behalf of the American Medical Rehabilitation Providers Association (AMRPA), I am submitting this letter regarding the proposed updates to the Medicare Advantage (MA), Part C and Part D programs through the 2019 Advance Notice and Draft Call Letter released by the Centers for Medicare and Medicaid Services (CMS). Our comments focus on concerns regarding MA enrollee access to medical rehabilitation services, particularly access to inpatient rehabilitation facilities (IRFs).

Background: Access Challenges As AMRPA has commented in response to prior call letters, within the MA program there are significant administrative hurdles to getting patients the post-acute care they need. We remain concerned—and increasingly so—that many MA plans continue to deny medically necessary inpatient rehabilitation care and are circumventing Medicare coverage rules in the process.

When Medicare beneficiaries are injured, become seriously ill or require surgery, they often require medical rehabilitation to regain functional losses. The acute hospital stay is often just the first step toward recovery and returning to a more normal life in the community. Patients frequently require a course of hospital-based rehabilitation that is intensive, rehabilitation physician-directed and coordinated, and delivered by a multidisciplinary team.

IRFs strive to continue the healing process and deliver the medical and nursing care needed while also improving the quality of life for patients recovering from surgical procedures, strokes, spinal cord injuries, brain injuries, amputations, hip fractures and many other conditions that decrease a person’s ability to function, live independently and perform common daily activities, such as walking, using a wheelchair, bathing or eating. For example, a patient who sustains a stroke may be left with permanent neurological deficits and need to overcome or adapt to physical, language and cognitive impairments. Other post-acute care settings generally provide less intensive and less coordinated rehabilitation services without the nursing care skills and hours or physician availability of the IRF. Due to the uniquely intensive medical and rehabilitation services provided in an IRF, Medicare has incredibly rigorous screening criteria and other regulatory requirements to ensure that each and every patient admitted to an IRF belongs there.

The agency has developed detailed coverage regulations for Medicare IRF coverage. These coverage rules also apply to both Part A fee-for- service and Part C Medicare Advantage beneficiaries. Medicare regulations are clear that MA plans must provide “all Medicare-covered services.” These covered services include “all services that are covered by Part A,” which are the “basic benefits” available to MA enrollees.

MA plans must comply with all Medicare coverage regulations and manuals. Medicare manuals are equally clear that an MA plan “must provide enrollees in that plan with all Original Medicare-covered services.” The relevant manual instructs that “[i] f the item or service is covered by Original Medicare under Part A or Part B, including Part B prescription drugs, then it must be offered.” Therefore, MA plans must determine IRF coverage using the Part A regulations at 42 C.F.R. §412.622 and other applicable guidance.

However, instead of following these Medicare IRF coverage criteria, many MA plans improperly apply private decision tools, such as Milliman and InterQual, to make coverage decisions that override clinical decision-making, both prospectively and retrospectively. The effect of this practice is to divert many enrollees who qualify for inpatient hospital rehabilitation to less appropriate, lower-acuity settings, such as nursing homes and homecare, inevitably decreasing their prospects for full recovery. This is why it is unsurprising that in its March 2017 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) once again found that MA enrollees were admitted to IRFs at approximately one-third the rate of Medicare fee-forservice beneficiaries in 2015.

AMRPA Magazine / April 2018 27

To illustrate the tension between standard MA operating procedures and best clinical practices, the American Stroke Association (ASA) and American Heart Association (AHA) emphatically recommend that all stroke patients receive their immediate post-acute care in the IRF setting. The ASA/AHA guidelines are based on years of clinical analysis, including the most comprehensive independent analysis ever undertaken in the field. However, many MA enrollees who suffer strokes are denied access to inpatient rehabilitation and redirected to nursing homes for their post-acute care. In one recent survey of our membership, AMRPA found that patients with a primary diagnosis of stroke constitute 30 percent of cases denied preadmission approval by MA plans. This practice directly contravenes evidence-based best practices and is purportedly based on the aforementioned decision support tools that MA plans refuse to divulge.

Further illustrating the deficiency in access to post-acute care provided by MA plans, independent researchers recently found that MA plan benefits are not designed to adequately meet enrollees’ post-acute and long-term care needs, and that postacute provider networks and cost-sharing restrict access to needed care. The study’s authors identified these practices as driving a unidirectional flow of higher-cost enrollees from enrollment in MA back to traditional fee-for-service Medicare Improper Use of Non-Medicare Guidelines A number of problematic practices by managed care organizations are contributing to this worsening phenomenon. Based on reports from AMRPA members, the rates of preadmission denials and retroactive claims denials have steadily risen as MA plans increasingly rely on proprietary guidelines such as Milliman and InterQual guidelines, defer to medical or clinical staff who lack rehabilitation expertise, and erect other administrative barriers that make appealing initial denials untenable for hospitalized patients, their caregivers, and the acute care hospitals forced to extend their stays until discharge plans are arranged.

These proprietary guidelines do not mirror Medicare coverage but are nevertheless being used to deny patients access to medically necessary and clinically appropriate medical rehabilitation services. MA plans often refuse to share their placement assessments with providers, caregivers or others on the basis that the underlying decision tool is proprietary. This posture puts patients in an unwinnable Catch-22 and flaunts one of the underlying premises for having uniform Medicare coverage policies that are available to all. AMRPA has sought to understand the Milliman product and through small-sample modeling it has become clear that virtually no patients are recommended for placement in the IRF setting, including those recovering from major strokes with paralysis and other debilitating injury and illness. Based on this modeling, 95 percent of reviewed cases qualifying for inpatient-level rehabilitation care were directed to a lower acuity setting, such as a nursing home or homecare. Even more frustrating, AMRPA members increasingly report that MA plans inform their enrollees that IRF care is not covered under their plan.

To avoid such blatant disregard for Medicare requirements, AMRPA requests that the final Call Letter instruct MA plans to apply CMS’ coverage regulations governing IRFs. CMS must ensure that MA plans are not designing benefits to discriminate against beneficiaries or discourage enrollment by inhibiting access to services or steering particular subsets of Medicare beneficiaries to specific coverage options.

For these reasons, AMRPA renews our request that CMS remedy this situation in the final Call Letter by explicitly instructing MA plans to: 1) refrain from using private decision tools to override clinical decision-making and subvert Medicare beneficiaries’ rights under the law; and instead 2) apply the existing Medicare coverage rules governing IRF care.

Disregard for MA Enrollee Appeal Rights Hospitalized MA enrollees are often precluded from exercising fundamental appeal rights in seeking clinically appropriate post-acute care. In the final Call Letter, CMS has an opportunity to ensure patients’ basic appeal rights will be met.

MA enrollees are often completely unaware of their rights to the same benefits of those enrolled in traditional Medicare, as well as their right to appeal a denial of a preauthorization for services in a particular setting. The most vulnerable beneficiaries are often at the greatest risk of being denied access to medically necessary rehabilitation services without knowledge of the decisions being made behind the scenes, and may lack the social or financial supports necessary to appeal without guidance.

Accompanying any preauthorization request, MA plans should be required to inform enrollees about their redetermination and appeal rights, including information about resources to help them navigate the process. There should also be a required disclosure of Medicare post-acute care coverage rules so Medicare beneficiaries receive adequate and explicit information about potential options upon admission to, and especially at discharge from, a short- term acute care hospital.

The operating procedures of MA plans erect numerous barriers, bureaucratic processes and delays, as well as unreasonable paperwork demands that restrict access to higher-acuity post-acute care settings, such as IRFs, and limit opportunities for timely redeterminations. MA plans frequently deny a referral to an IRF but decline to provide a copy of the denial notice to the patient or caregiver, thereby hindering the possibility of a successful appeal. MA plans are presently required to provide these notices upon request, but in light of the obvious access problems, CMS should instruct MA plans to provide

28 AMRPA Magazine / April 2018

denial information to the patient automatically, and to other health care providers whenever requested by the patient, a caregiver, or providers involved in delivering the patient’s acute or planned post-acute care.

Further, managed care organizations often employ reviewers who lack relevant clinical experience to advise on referrals for medical rehabilitation. Based on AMRPA members’ experiences, it is rare for an MA plan’s medical reviewer to have any expertise or even baseline knowledge in medical rehabilitation, and thus most reviewers are often unable to understand the patient’s rehabilitation needs. In contrast, IRFs are required to employ a rehabilitation physician with specialized training in preadmission review to determine the appropriateness of a patient’s admission to an IRF, consistent with Medicare regulations. Despite this expertise, our members report that a substantial number of MA plans will only correspond with the referring physician from the acute care setting, who may be less qualified to make this determination, and also often refuse to correspond with the medical director of the referred-to setting, such as an IRF. To ensure patients are entitled to informed medical review, MA plans should be required to elevate an appeal to a clinician with relevant expertise within a reasonable amount of time, certainly within 24 hours, regardless of the day of the week or weekend. Further, CMS should direct MA plans to correspond with any knowledgeable clinician involved in the discharge planning process when making referral determinations and redeterminations.

MA plans often maintain unreasonably limited hours for considering preauthorization requests and redeterminations and stretch out their review processes over several days, essentially forcing hospitalized patients to be discharged to alternative settings. Current appeal processes permit MA plans to take up to 72 hours to render an initial decision or redetermination.

Moreover, AMRPA members report that if a determination period ends on a Friday, plans will often respond that there is no one available to reconsider the determination until the following week.

The aggregate effect of the high rate of initial denials, combined with administrative hurdles that slow the redetermination process, is that patients are stuck in the acute care setting, which is clinically inappropriate, introduces additional health risks to the patient and costs to the health care system. Additionally, MA plans often waive precertification requirements for subacute rehabilitation settings such as nursing homes. As a result, hospital personnel are pressured to discharge to these settings rather than wait days for MA plans to consider and reconsider referrals for inpatient rehabilitation. Over time, acute care providers and their discharge planning personnel become less willing to assist patients in obtaining the requisite approvals to access the appropriate level of rehabilitation care, especially when the administrative timeline needlessly prolongs the acute care stay as well as in light of increasing pressures to limit inpatient services Instead, discharge personnel increasingly make referrals only to post-acute care settings that they know will not be denied by the MA plan.

CMS should revisit these practices and use the Call Letter as an opportunity to eliminate unnecessary requirements designed to frustrate meaningful appeals. The agency must ensure 24/7 access by enforcing existing timelines and should work with plans to further expedite their processes to enable timely appeals. At a minimum, MA plans should be able to review and process post-acute care preauthorizations and redeterminations seven days a week and should never take more than 24 hours to respond. To that end, we request that all hospitalized patients needing a placement/admission determination be entitled to the emergency protocols with regard to medical review.

AMRPA appreciates that Draft Call Letter acknowledges these concerns and CMS’ admonishment that “[e]ffective processing of Part C organization determinations and reconsiderations . . . are critical areas of the MA and Part D program.” We are encouraged by CMS pursuing additional evaluation of “sponsoring organizations’ compliance with effectuating appeals and provider outreach requirements, as well as appropriate clinical-decision making and notification to beneficiaries.” We believe this scrutiny is well placed. However, in addition to ensuring technical conformance with regulations, more must be done to also ensure that hospitalized patients actually receive decisions that are timely enough to impact their future trajectory of care. Without this assurance, appeal rights are hollow.

To that end, AMRPA urges CMS take steps in the final Call Letter to ensure MA plan enrollees have a meaningful opportunity to appeal improper coverage denials. Specifically, CMS should direct MA plans to: (1) provide Medicare postacute care coverage rules so beneficiaries receive adequate information about potential upon discharge from a short- term acute care hospital (2) automatically provide a copy of the denial notice to the patient or caregiver; (3) inform enrollees about their redetermination and appeal rights; (4) process preauthorizations and redeterminations within 24 hours for all hospitalized patients seeking authorization for post-acute care admissions; (5) enforce these timelines on weekends and holidays; (6) consult clinicians with relevant expertise for placement decisions; and (7) be willing to communicate with the medical director of the referred-to setting.

Inadequate Measurement of MA Performance There are currently insufficient incentives for MA plans to authorize referrals to inpatient medical rehabilitation settings, which can cost slightly more than non-hospital settings in the short term, but produce better outcomes and savings in the longterm. Notably, patients’ long-term survival and outcomes have been shown to vary significantly by post-acute setting, hence the AHA/ASA recommendation. The most robust study on this topic, performed by Dobson DaVanzo & Associates, found

AMRPA Magazine / April 2018 29

that Medicare beneficiaries admitted to IRFs for their immediate post-acute care had significantly better outcomes across a range of quality indicators compared to highly matched beneficiaries who received their immediate post-acute care in a SNF. According to the findings, modestly higher spending on immediate post-acute care in the IRF setting was generally offset over the course of the two year period. MA plans are not currently held accountable for many relevant quality outcomes, such discharge back to the community, or long-term health outcomes, such as days in the community, and thus systematically fail to make an investment in enrollees’ long-term health. Since these quality indicators do not impact MA plans’ payment, decision-making too often ignores consideration of what is best for the patient. AMRPA would like to work with CMS and other stakeholders to rectify this overarching shortcoming of the MA program.

In the meantime, we encourage CMS to enhance transparency about MA utilization of post-acute care services. While individual medical providers experience inappropriate denials of patient referrals on a daily basis, CMS appears to lack robust data on the aggregate number (and proportion) of placement decisions, including the total number of patients being referred to different post-acute care settings, the total numbers (and proportion) of denials that are successfully and unsuccessfully appealed, and the number of retroactive/post-payment denials and appeals, among other critical data. CMS should promptly institute reporting requirements for MA plans to begin recording this baseline data in uniform data sets and be required to report this information to CMS on a quarterly basis.

Additionally, AMRPA encourages CMS to make changes in the final Call Letter to audit plan performance along additional dimensions including compliance with Medicare coverage rules and beneficiary protections. AMRPA appreciates that CMS includes several appeals measures in the Star Ratings program, relating to the timeliness and reliability of decision-making, because these metrics are critical indicators of overall plan performance. We support CMS’ proposed expansion of this measure set in the Draft Call Letter.

AMRPA is further encouraged by CMS’ continued interest in adopting “enhanced measures of beneficiary access” including “compliance with effectuating appeals and provider outreach requirements, as well as appropriate clinical-decision making and notification to beneficiaries.”

We urge CMS to follow through on these proposals and to adopt additional measures on these dimensions in the near term.

Additionally, we think CMS should do more than just require MA plans to submit data on appeals, but should audit the information to ensure its accuracy and conformance with regulatory requirements. CMS should also take further steps beyond just reducing Star Ratings for MA plans with appeals deficiencies, but also promptly correct any plan performance that is consistently out of alignment with official policy.

AMRPA appreciates the opportunity to provide comments on the Draft Call Letter and is hopeful that many of these concerns can be addressed in the final. If you have any questions regarding our comments, please contact Carolyn Zollar, JD, AMRPA’s Executive Vice President for Government Relations and Policy Development at +1-202-223-1920 or czollar@amrpa.org, or AMRPA’s Washington Counsel Martha Kendrick, JD, at +1-202-887-4215 or mkendrick@akingump.com.

Sincerely,

Richard Kathrins, Ph.D. Chair, AMRPA Board of Directors President and CEO, Bacharach Institute for Rehabilitation

30 AMRPA Magazine / April 2018

2018 Medicare Participating Post-Acute Care Providers in the U.S. Each year, AMRPA magazine publishes statistics on the number of inpatient rehabilitation hospitals and units (IRH/Us), skilled nursing facilities (SNFs), long-term care hospitals (LTCHs) and comprehensive outpatient rehabilitation facilities (CORFs). The data is provided from the CMS Online Survey, Certification and Reporting (OSCAR) database.

Type of Provider

1996

1998

2000

2002

2004

2006

2008

2010

2012

2013

2014

2015

2016

2017

2018

Skilled Nursing 15,553 15,035 14,825 14,792 14,929 15,006 15,041 15,067 15,129 15,685 15,712 15,189 15,233 15,279 15,643 Facilities (SNFs) 9,886 9,386 7,528 6,935 7,341 8,587 9,382 10,945 12,121 12,384 12,612 12,463 12,318 12,184 11,841 Home Health Agencies (HHAs) 1,048 1,097 1,128 1,295 1,359 1,229 1,195 1,189 1,161 1,162 1,161 1,172 1,179 1,186 1,178 Inpatient Rehabilitation Facilities (IRFs) 185 207 Long-Term 253 272 317 393 393 428 437 436 430 424 427 424 410 Care Hospitals (LTCHs) 550 516 544 638 627 517 401 295 268 234 219 207 196 184 Comprehensive 403 Outpatient Rehabilitation Facilities (CORFs) Source: Centers for Medicare & Medicaid Services (CMS) OSCAR Database, As of February 2018, CMS

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AMRPA: Working Together to Preserve Access to Medical Rehabilitation

Samantha Schwarz, AMRPA MemberTo Services Coordinator, 202-207-1132, sschwarz@amrpa.org AMRPA: Working Together Preserve Access To Medical Rehabilitation

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

AMRPA Magazine / April 2018 31

2018 PPS-Excluded Inpatient Rehabilitation Hospitals and Units, Long-term Care Hospitals, CORFs and Beds By State Each year, AMRPA magazine provides a breakdown of the number of inpatient rehabilitation hospitals and units (IRH/Us), skilled nursing facilities (SNFs), long-term care hospitals (LTCHs) and comprehensive outpatient rehabilitation facilities (CORFs), and bed counts by state. The data is taken from CMS’s Online Survey, Certification and Reporting (OSCAR) database as of March 2018.

State Alaska Alabama Arizona Arkansas California Colorado Connecticut District Of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusettes Michigan Minnessota Mississippi Montana Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Total

Rehab Hospitals 6 10 8 7 4 1 1 1 16 6 1 1 4 7 6 5 20 1 2 6 2 1 6 2 3 2 8 5 1 2 12 4 18 3 1 7 11 60 2 9 1 5 3 1 282

Rehab Hospital Bed Count 393 566 521 512 266 60 137 34 1,182 324 100 30 473 394 356 338 572 100 146 722 174 33 410 142 181 185 781 230 150 213 684 182 1,520 103 40 420 612 3,382 124 415 102 290 171 41 17,811

Rehab Units 2 10 15 17 80 15 5 1 2 35 23 6 47 28 15 13 13 28 4 4 41 16 11 4 23 8 13 3 7 6 54 23 4 40 19 8 61 4 5 13 4 24 73 10 1 17 18 3 18 2 896

Source: Centers for Medicare & Medicaid Services OSCAR Report, March 2018

32 AMRPA Magazine / April 2018

Rehab Unit Bed Count 20 279 365 353 2,095 262 81 16 78 1,327 547 114 1,278 634 244 195 395 565 64 98 974 331 315 79 491 152 336 71 263 123 1,843 746 109 945 472 148 1,475 98 87 349 77 553 1,774 167 35 436 305 39 388 27 22,218

LTCH Hospitals 1 9 5 7 19 7 3 2 1 24 16 1 3 7 11 2 4 8 32 2 12 19 2 10 1 10 4 6 8 3 3 10 2 25 12 1 17 1 6 1 8 66 4 6 2 2 5 410

LTCH Bed Count 60 369 308 258 1,630 400 665 142 35 1,634 836 9 140 948 581 80 157 630 1,617 189 2,910 999 346 420 40 516 204 369 505 106 686 525 72 1,386 559 79 702 495 308 24 356 4,149 135 492 120 60 204 27,455

CORFs 1 4 1 8 1 3 40 2 2 1 1 7 3 5 1 1 2 6 12 5 1 2 1 12 2 1 4 48 4 1 1 1 184

As part of AMRPA’s civic engagement series, we provide updates on upcoming elections to ensure that our members remain active in shaping their federal representation in Congress. Primary elections will be picking up in the coming months, so you will find more updates on upcoming primaries below, as well as online resources where you can get more information.

The following 11 states will be holding primary elections in May: Indiana – May 8, 2018 Nine House seats are up for election, including seven incumbents and two vacant seats.

One seat in the Senate is up for election.

North Carolina – May 8, 2018 North Carolina has 13 House seats in the delegation. All incumbents are running for reelection.

There are no Senate seats up for election.

Ohio – May 8, 2018 Ohio has 16 House seats in the delegation, including 15 incumbents and one vacant seat.

There is one Senate seat up for election.

West Virginia – May 8, 2018 Three House seats are up for election, including two incumbents and one vacant seat.

There is one Senate seat up for election.

Idaho – May 15, 2018 Idaho has two House seats in the delegation, with one incumbent running for reelection and one vacant seat.

No Senate seats are up for election.

Nebraska – May 15, 2018 Nebraska has three House seats up for election; all incumbents are running for reelection.

There is one Senate seat up for election.

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 in its delegation, with 12 incumbents running and six vacant seats.

There is one Senate seat up for election.

Arkansas – May 22, 2018 Arkansas has four House seats up for election; all incumbents are running for reelection.

No Senate seats are up for election.

Georgia – May 22, 2018 Georgia has 14 House seats in its delegation; 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.

The following 17 states will be holding primary elections in June: Alabama – June 5, 2018 Seven House seats are up for election. All incumbents are running for reelection.

There are no Senate seats up for election.

California – June 5, 2018 California has 53 House seats in the delegation, 51 incumbents and two open seats.

There is one Senate seat up for election.

Iowa – June 5, 2018 In Iowa, four House seats are up for election. All incumbents are on the ballot.

There are no Senate seats up for election.

AMRPA Magazine / April 2018 33

Montana – June 5, 2018

Colorado – June 26, 2018

Montana’s one House seat is up for election. The incumbent is running for reelection.

There is one Senate seat up for election.

Seven House seats are up for election in Colorado. Six incumbents and one open seat.

There are no Senate seats up for election.

New Jersey – June 5, 2018

Maryland – June 26, 2018

The New Jersey delegation consists of 12 House seats, with 10 incumbents and two open seats.

There is one Senate seat up for election.

Maryland has eight House seats up for election, with seven incumbents and one open seat.

There is one Senate seat up for election.

New Mexico – June 5, 2018

Mississippi – June 26, 2018

Three House seats are up for election in New Mexico. One incumbent and two open seats.

There is one Senate seat up for election.

Four House seats are up for election in Mississippi, three incumbents and one open seat.

There are two Senate seats up for election. One incumbent and one open seat.

South Dakota – June 5, 2018 One open House seat is up for election.

There are no Senate seats up for election.

Maine – June 12, 2018 There are two House seats in the delegation. Both incumbents will be running for reelection.

There is one Senate seat up for election.

Nevada – June 12, 2018 Nevada has four House seats up for election, two incumbents and two open seats.

There is one Senate seat up for election.

North Dakota – June 12, 2018 One open House seat is up for election in North Dakota.

There is one Senate seat up for election.

South Carolina – June 12, 2018 South Carolina has seven House seats up for election, Six incumbents and one open seat.

There are no Senate seats up for election.

Virginia – June 12, 2018

Oklahoma – June 26, 2018 Oklahoma has five House seats in its delegation. Four incumbents are running and there is one open seat.

There are no Senate seats up for election.

Utah – June 26, 2018 Utah has four House seats up for election; all incumbents are running for reelection.

There is one open Senate seat up for election.

Be sure to visit our website for more up-to-date election information. You can find the 2018 Congressional Elections page under the Advocacy tab on www.amrpa.org. If you have any questions or feedback, contact Catherine Beal at cbeal@amrpa.org or +1-202-223-1920.

For more information about your local representatives, visit the following websites: Find your House representative here: www.house.gov/ representatives/find-your-representative and Senators here: www.senate.gov/general/contact_information/senators_ cfm.cfm.

In Virginia, 11 House seats in the delegation, ten incumbents and one open seat.

There is one Senate seat up for election.

For more voting information, and to find out if you are registered, visit www.usa.gov/voting.

34 AMRPA Magazine / April 2018

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36 AMRPA Magazine / April 2018