AMRPA Magazine | April 2020

April 2020 • Vol. 23, No.4

April 2020 • Vol. 23, No. 4

The official publication of the American Medical Rehabilitation Providers Association (AMRPA) Robert Krug, MD Chair, AMRPA Board of Directors, President and CEO Mount Sinai Rehabilitation Hospital Medical Director, PM&R Service Line John Ferraro, MS AMRPA Executive Director Kate Beller, JD AMRPA Executive Vice President for Government Relations and Policy Development Remy Kerr, MPH AMRPA Health Policy and Research Manager Patricia Sullivan AMRPA Senior Editor Shirley Soda Design and Layout AMRPA Magazine, Volume 23, 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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by American Medical Rehabilitation Providers Association.

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POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 1280, Washington, DC 20045

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Table of Contents Letter from the Chair

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Legislative Update

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Final Rules Released on Interoperability and Patient Health Data Access

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Improving the Patient’s Outcomes

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AMRPA Submits Comments on U.S. News Proposed Ranking Methodology for Rehabilitation Hospitals

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AMRPA Responds to Medicare Advantage Advanced Notice

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AMRPA Represents the Power of Medical Rehabilitation at Brain Injury Awareness Day 2020

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CMS Proposes Three Year Extension of Joint Replacement Model

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Letter from the Chair

Robert Krug, MD President and CEO Mount Sinai Rehabilitation Hospital Medical Director, PM&R Service Line

Responding in an Unprecedented Situation The entire health care industry is facing a truly unprecedented situation as it works to respond to the COVID-19 pandemic. The challenges facing my own hospital seemingly grow and change on an hourly basis, and I cannot imagine what new issues will be facing our industry by the time this letter is published. For that reason, I want to convey a few critical points that our members can reference throughout this emergency.

First, and most importantly, AMRPA is fully committed to the safety and well-being of our members and their patients. I believe that industry-wide education and communication is absolutely critical at this juncture, and to that end, we have and will continue to convene informational calls so that we can learn and share “best practices” with respect to COVID-19 response. I want to convey my utmost appreciation to all of our leaders who have taken the time to participate on these calls in the midst of their own hospitals’ demands. Furthermore, our staff is responding to member questions on a daily basis, and the AMRPA website provides the most up-to-date information on federal guidance for our members’ reference.

Second, we will continue our zealous advocacy for our patients by ensuring that all inpatient rehabilitation hospitals and units around the country are fully able to respond to the needs of their communities. We are in contact with policy-makers every day to relay the current and emerging issues facing our industry, and working to ensure that all appropriate waivers and/or guidance are provided.

Finally, AMRPA will ensure that decisions on all future AMRPA events are made fully with the safety of our members in mind. We will continue to keep you up to date about the upcoming regional events and plans for the 2020 Fall Conference. With respect to our Spring Conference, we are looking to deliver some of the planned content and education via webinar or other type of event in the near future.

Your hospitals’ efforts to date have been extraordinary and truly reflect the value of inpatient rehabilitation and our commitment to our patients. If AMRPA can provide any support or assistance to help your hospital in these times, please do not hesitate to contact me or AMRPA staff.

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Changing the Game of Prior Authorization: The Patient Perspective. Martha E. Gaines, JD, LLM; Austin D. Auleta, BA; Donald M. Berwick, MD, MPP. JAMA. Published online February 3, 2020. doi:10.1001/jama.2020.0070

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Refocusing Medication Prior Authorization on Its Intended Purpose. Jack S. Resneck Jr, MD. JAMA. Published online February 3, 2020. doi:10.1001/ jama.2019.21428

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Find new and exciting opportunities in AMRPA’s Career Center.

Our Career Center provides services and resources to help the medical rehabilitation field meet their professional goals.

All rehabilitation professionals may browse and apply for jobs at no cost, and AMRPA members will receive discounted rates for posting positions.

Visit our Career Center Here:

careercenter.amrpa.org

Begin by creating your free Career Cast account, which can be found on the top right hand corner of the website.

From there, you can upload and manage multiple resumes, browse through hundreds of job postings, and even research salaries of the positions in question! AMRPA members and affiliates may also purchase Posting Packages at a standard, premium, or platinum level.

AMRPA members will receive a 50% discount on all job postings.

For questions about our Career Center, please contact Elizabeth Katsion, AMRPA Member Services Associate, at ekatsion@amrpa.org or 202-207-1102.

Legislative Update

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

Highlights: »

On March 11, 2020, the World Health Organization declared the coronavirus outbreak a pandemic after previously resisting the classification.

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On March 6, President Trump signed the $8.3 billion emergency coronavirus legislation into law after a swift passage by both the House and Senate.

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On March 9, the Department of Health and Human Services (HHS) finalized two rules on interoperability and patient access to health data.

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On February 20, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule to extend the Comprehensive Care for Joint Replacement (CJR) model for three years through 2023, while also making changes to the episode of care definition and target price calculation.

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A continued focus will be negotiations on surprise medical billing and drug pricing legislation as Congress eyes a May 22, 2020, deadline for a number of important expiring health programs as a likely vehicle for major health policy changes. This timing could change given the coronavirus crisis.

Coronavirus Emergency Supplemental Signed into Law As the coronavirus (COVID-19) continues to spread internationally and throughout the United States, Congress quickly passed an $8.3 billion emergency supplemental spending bill for coronavirus response. President Trump signed the measure into law on March 6, as new reports indicate the number of COVID-19 cases worldwide now exceeds 100,000. The funding package provides more than $3 billion for research and development related to potential treatments, testing and vaccines. While Democrats had sought to include language that would have given the federal government more authority to regulate prices of COVID-19 drugs and vaccines, the final bill reiterates existing policy regarding the Federal Acquisition Regulation’s fair and reasonable pricing requirement. Notably, the supplemental includes provisions that would allow qualified Medicare providers to offer telehealth services during a public health emergency, waiving originating site requirements and restrictions on using telephones as long as the phones have audio and video capabilities. The Congressional Budget Office (CBO) scores the telehealth provisions as costing $490 million in fiscal years 2020 through 2022. The supplemental also provides $950 million to the Centers for Disease Control and Prevention (CDC) to distribute to states, localities, territories and tribes for coronavirus preparedness and response efforts, including hospital and health system preparedness. Community health centers also received $100 million to prevent and respond to the coronavirus.

Annual congressional hearings held over the past several weeks to discuss the president’s FY 2020 Budget Request with top officials from the administration were almost solely focused on COVID-19 federal response efforts and what steps may be needed to slow the spread of the virus. Senate Majority Leader Mitch McConnell (R-KY) has indicated this will be a “relatively regular appropriations process” based on the previously negotiated agreement on top-line spending levels for FY 2021 in last year’s Bipartisan Budget Act. Significant differences exist between the parties on policy and spending priorities; however, we expect the House and Senate will pass a stopgap spending measure prior to the end of the fiscal year (September 30) that will run until a few weeks past the November election. The House Appropriations Committee announced it would start subcommittee markups on April 21, assuming no change in plans due to the coronavirus outbreak.

Administration and Congress Consider Economic Stimulus President Donald Trump and his senior economic advisers are considering several additional measures to address the economic impact of COVID-19 after signing an $8 billion emergency funding bill. Additional policy proposals under consideration reportedly include tax relief measures for affected industries; payroll tax cut; paid sick leave; and government-backed relief to the specific geographic regions in the country hit hard by the outbreak. On March 9, House Speaker Nancy Pelosi (D-CA) and

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Senate Minority Leader Chuck Schumer (D-NY) called on the administration to prioritize paid sick leave; ensure unemployment insurance benefits are available and sufficient for workers who may lose their jobs from the economic impacts of the epidemic; clear protections for frontline workers who are in contact with people who have been exposed or are suffering from the virus; access to free coronavirus testing; and affordable health care treatment for any non-covered coronavirus-related costs.

Democratic leaders also urged the administration to use our country’s emergency response mechanisms to mobilize resources and facilities in order to respond to surges in demand.

Senate Finance Committee Chair Chuck Grassley (R-IA) reportedly noted that, “everything is on the table,” and Senate Appropriations Committee Chair Richard Shelby (R-AL) mentioned that he would welcome a stimulus package if it is paid for, pointing to an infrastructure spending bill that would attract bipartisan support. As we go to press, several Republican lawmakers appear reluctant to implement a stimulus package, arguing that it is too early, according to various reports.

Prior Authorization Legislation Update Regarding a top legislative priority for AMRPA, lead sponsors of House Resolution 3107, the Improving Seniors’ Timely Access to Care Act of 2019, recirculated a new draft to engaged stakeholders. The revised legislation includes a number of changes from the introduced version, primarily to clarify ambiguous provisions in the earlier draft and to appease concerns raised by managed care and payor groups. Notably, the bill has eliminated public reporting of prior authorization utilization data in favor of new beneficiary education resources.

Unfortunately, from the rehab provider perspective, the changes were not very positive and in particular, the sponsors did not accommodate requests from AMRPA and other providers.

AMRPA staff and outside counsel are working to further analyze and assess the impact of the revised legislation on rehabilitation providers. Meanwhile, several members of the Senate Finance Committee are working to introduce companion legislation.

Senate sponsors are allegedly open to revising some of the key provisions, such as putting parameters around the definition of “real time” decision-making. At present, there are no commitments from the committees or leadership to move the legislation in the near future.

CMS Releases COVID-19 Guidance to Providers and Payors On March 4, the Centers for Medicare and Medicaid Services (CMS) issued a “call to action” to Medicare-participating health care providers, specifically nursing homes and hospitals, to ramp up their infection control procedures to control the spread of COVID-19. State Survey Agencies and Accrediting Organizations are now required to focus their facility inspections entirely on issues related to infection control and other serious health and safety threats, such as allegations of abuse. CMS released a memorandum detailing how it will focus on infection control surveys and protocols to handle patients who may have or be suspected of having COVID-19. CMS also described the process for transferring patients between nursing homes and hospitals in cases where COVID-19 is suspected or diagnosed. Further,

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the agency details the circumstances under which health care providers should take precautionary measures (like isolation and wearing masks) for patients and residents diagnosed with COVID-19 or showing signs and symptoms of COVID-19. CMS has provided an infection prevention specialist to CDC’s Atlanta headquarters to assist with real-time guidance development.

On March 10, CMS followed up with additional COVID-19 guidance for home health agencies (HHAs) and dialysis facilities, as well as protective mask guidance for health care workers on the frontline of care. CMS also issued a memorandum to Part D plans and Medicare Advantage (MA) plans to inform them of the flexibilities they have to provide health care coverage to Medicare beneficiaries for COVID-19 testing, treatments, and prevention. Notably, they exercised enforcement discretion for telehealth services in MA, including cost-share waivers or reductions, and use of “telehealth in any geographic area and from a variety of places including the beneficiaries’ home.”

Additional flexibilities include waiving cost sharing for COVID-19 tests and treatments, removing prior authorization requirements, waiving prescription refill limits and relaxing restriction on home mail delivery of prescriptions. HHAs were advised to monitor the CDC website and follow their infection prevention and control practices. They were also advised to use CMS guidance and resources to address potential and confirmed COVID-19 cases and mitigate transmission, including screening, treatment and transfer to higher-level care, if appropriate. The mask guidance aligns CMS policy with recent changes to CDC and the Food and Drug Administration (FDA) mask and respirator guidance due to COVID-19 and demands on the supply. CMS confirmed that masks are an acceptable alternative to respirators for most health care services.

Interoperability Rules Finalized On March 9, CMS and the Office of the National Coordinator for Health Information Technology (ONC) released final rules to accelerate health information interoperability and improve patient access to their health data. The ONC rule focuses primarily on standardized application programming interfaces (APIs) that must be adopted by the health care industry, as well as implementing information blocking provisions required by the 21st Century Cures Act. Health Level 7® (HL7) Fast Healthcare Interoperability Resources® (FHIR) Release 4.0.1 is noted as a required standard API framework. The CMS Rule finalized that by January 1, 2021, CMS-regulated payers must implement and maintain a secure, standards-based API allowing patients to access claims and encounter information via a thirdparty application of their choice and make provider directory information publicly available via a standards-based API. By January 1, 2022, CMS-regulated payers must implement a process for exchanging certain patient clinical data (specifically the U.S. Core Data for Interoperability (USCDI) version 1 data set) at the patient's request. By April 1, 2022, states must exchange certain enrollee data for individuals dually eligible for Medicare and Medicaid, including state buy-in files and MMA files, on a daily basis.

CMS Proposes to Update CJR Model and Extended Three Additional Years On February 20, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule to extend the Comprehensive Care for Joint Replacement (CJR) model for three years through 2023. Proposed changes include incorporating outpatient hip and knee replacements into the episode of care definition, the target price calculation, the reconciliation process, the beneficiary notice requirements, gainsharing caps, and the appeals process.

Additionally, to allow time to evaluate the proposed changes, the rule proposes extending the length of the CJR Model for an additional three years, through December 31, 2023, for certain participant hospitals. Comments are due on April 20, 2020.

*** As we go to press, members of Congress and federal departments and agencies are consumed by the coronavirus response, and we understand that AMRPA members are facing increased demands as hospitals respond to the COVID-19 emergency as well. Thank you for all you are doing to keep your patients and communities safe. Lawmakers and the Trump administration continue to grapple with how to effectively prevent, respond and prepare for this epidemiological challenge, and AMRPA is thinking creatively and thoughtfully about how to best to move forward with its policy agenda. We do appreciate your patience and of course, the care you are providing to your patients during this difficult and most challenging time.

Affordable Care Act Developments On March 2, the Supreme Court announced that it would hear the Texas v. United States case during the term beginning October 2020. Oral arguments have not yet been scheduled, but it is likely that a final decision on the constitutionality of the Affordable Care Act (ACA) could be handed down in early 2021.

Stay tuned for developments. .

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AMRPA Schedule of Events AMRPA leaders continue to monitor the unfolding COVID-19 pandemic and will keep you notified if any of the dates of in-person events change.

CONFERENCE DATES AMRPA 2020 Fall Conference October 4-7, 2020 Renaissance Dallas Hotel Dallas, Texas CALL FOR ABSTRACTS NOW OPEN! AMRPA REGIONAL MEETING SERIES Friday, May 8, 2020 Nashville, Tennessee Hosted by HCA Healthcare Friday, June 5, 2020 West Orange, New Jersey Hosted by Kessler Institute for Rehabilitation Wednesday, July 15, 2020 Denver, Colorado Hosted by Vibra Rehabilitation Hospital of Denver MEMBERS-ONLY CALLS Wednesday, June 3, 2020, Noon - 1:00 p.m. ET Wednesday, September 13, 2020, Noon - 1:00 p.m. ET Wednesday, November 10, 2020, Noon - 1:00 p.m. ET eRehabData® CLINICAL TRAINING WEBINAR SERIES Free for eRehabData subscribers only Tuesday, April 7, 2020: Nursing and Therapy Documentation Tips Tuesday, May 5, 2020: Physician Documentation Tuesday, June 2, 2020: Managing Outcomes with eRehabData Visit eRehabData.com for more Information.

Please visit www.amrpa.org for registration information.

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Final Rules Released on Interoperability and Patient Health Data Access

Peter W. Thomas, JD, Principal, Powers Pyles Sutter & Verville, PC

On March 9, 2020, the U.S. Department of Health and Human Services (HHS) released two long-awaited final rules instituting new federal policies addressing patient health data access, interoperability and information blocking. The Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access final rule governs payers and health care providers, and will go into effect 60 days from the document’s publication in the Federal Register. AMRPA submitted detailed comments to the proposed Interoperability and Patient Access rule, which can be found here. The Office of the National Coordinator for Health Information Technology (ONC) also released a related rule, the 21st Century Cures Act final rule, which implements additional policies to advance interoperability.

The White House released a statement on the issuance of these rules, “Delivering the Future of Healthcare,” which can be accessed here. CMS also released a fact sheet on the Interoperability and Patient Access rule, and ONC’s information about the 21st Century Cures Act rule can be found here.

Joseph Nahra, Legislative Director, Powers Pyles Sutter and Verville, PC

These rules build on CMS’ ongoing efforts to—as it states—increase the availability of patient health care data and ease the flow of information between providers, payers, patients, and other stakeholders to enhance care coordination and improve health outcomes. While the majority of the provisions in these rules will primarily impact a range of CMS-regulated payers, there are portions of the rule that will affect hospitals and other health care providers specifically.

While both rules were formally proposed on February 11, 2019, many in the health care industry have been awaiting action by the agencies for much longer. The 21st Century Cures Act, signed into law in December 2016, included a requirement for the HHS secretary to conduct rulemaking around interoperability and information blocking within a year of enactment, though the rules were long delayed within the agency.

Impact on Hospitals and Other Providers There are two major provisions in the CMS rule that will have a direct impact on hospitals, including inpatient rehabilitation hospitals and units (commonly referred to as “IRFs”).

CMS’ stated goal for clinicians and hospitals in the rule is to ensure “that health care providers have ready access to health information about their patients, regardless of where the patient may have previously received care.” Additionally, the rule seeks to ensure that improved interoperability reduces burden on health care providers.

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Discharge Notifications The most significant impact to hospitals will come from newly required Admission, Discharge, and Transfer (ADT) notifications.

The rule will modify the Medicare Conditions of Participation (CoPs) for hospitals, critical access hospitals (CAHs), and psychiatric hospitals to require facilities to send electronic ADT notifications to receiving hospitals or other providers, as identified by the patient, upon discharge from emergency rooms or after receiving inpatient services.

These new requirements will be finalized in the CoPs at § 482.24 (d), under the “Standard: Electronic notifications” subsection. The specific requirements will include a mandate to send automated notifications, either directly or through an intermediary for health information exchange, of a patient’s discharge or transfer from a hospital emergency department or from inpatient services, to “all applicable post-acute care services providers and suppliers,” and to any of the following as appropriate for care coordination: the patient’s established primary care practitioner, the patient’s primary care practice group or entity and/or another practitioner, group or entity identified by the patient as being primarily responsible for their care. These requirements will be duplicated in the CoPs for psychiatric hospitals and CAHs. This means that IRFs will receive ADT notifications from acute care hospitals upon admission of patients being discharged from acute care hospitals and will generally be responsible for sending ADT notifications to other providers once their patients are discharged from the IRF. AMRPA opposed applicability to IRFs of the ADT provisions because the proposal was viewed by AMRPA leadership as premature and lacking in clarity. CMS chose to proceed with this requirement but allowed exceptions for hospitals without sufficient electronic health record capabilities.

Prohibitions on Information Blocking The 21st Century Cures Act provided a statutory definition for information blocking, referring to practices of “withholding data, or intentionally taking action to limit or restrict the compatibility or interoperability of health IT.” This is viewed as a serious threat to full interoperability by CMS, and the rule notes that CMS is aware of instances in which vendors of health IT and electronic health records may take part in such practices in order to maintain their customer base and impede competition.

The rule contains a provision, supported by AMRPA, to publicly report individual providers and hospitals that engage in certain conduct CMS deems to be information blocking in order to help deter the practice. Under the Quality Payment Program (QPP) and the Medicare Fee-for-service Promoting Interoperability Program, providers are required to attest to a variety of statements about their practice and report the information to CMS. Specifically for hospitals, there are three attestation statements regarding the prevention of information blocking that hospitals and CAHs must attest for the Promoting Interoperability Program, requiring three “yes” answers as part of demonstrating that the facility is a meaningful EHR user.

Under the new rule, CMS will post on a publicly available CMS website a list of all eligible hospitals or CAHs who responded “no”

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to any of these statements. CMS did not yet specify where such data on hospitals would be posted, but for provider-level data from the QPP program, these would be posted on CMS’ Physician Compare website. Like the process for the CMS star ratings program, CMS will conduct a 30-day preview period for facilities to review their information and contest any errors. No information will be posted regarding incomplete attestations, which CMS defines as any statements where a “yes” or “no” response is not submitted. This provision was finalized as proposed without modification.

In addition to the provisions described above, hospitals, health systems and clinicians will likely see the impact of increased patient data accessibility in their provision of care. As patients become more comfortable with accessing their data, and as data becomes more interoperable for patients moving across providers and payers, care coordination should be enhanced, and providers should be able to have a more complete picture of patients’ histories and current conditions. However, there will also likely be some “growing pains” as those entities impacted by the rule develop their new standards for data sharing as outlined below.

Providers should prepare for a learning curve as implementation proceeds.

Additional Provisions Most of the additional provisions from the proposed rule were finalized without significant modification. While these may not directly apply to hospitals, it will be important for providers to understand coming changes and how they may impact the process of care provision and coordination.

Patient Access to Medical Records As proposed last year, CMS will require payers regulated by the agency, defined as Medicare Advantage organizations, Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on the Affordable Care Act exchanges, to implement a standards-based patient access Application Programing Interface (API).

These programs will be used to allow patients to easily access their claims and clinical data and transfer it between payers. These APIs will have to conform with technical standards outlined in the ONC rule, currently determined as the Fast Healthcare Interoperability Resources (FHIR) Release 4.0.1 standard. FHIR is a standard developed and maintained by the not-for-profit Health Level Seven International organization. This functionality is intended to mesh with CMS’ Blue Button initiative, which currently allows beneficiaries and third-party applications to access and transfer Medicare claims data.

Additionally, CMS is requiring that payers facilitate care coordination by ensuring interoperability (including standardized data elements) of claims data for payer-to-payer data exchange.

Patients will be able to request that payers send information to any other payer identified by the enrollee, and data must comply with, at a minimum, the standards defined by the United States Core Data for Interoperability (USCDI) version 1.

Provider Directory API CMS payers will be required to provide standardized information about their provider networks available through an API as well, conforming to the same FHIR standards as the patient access APIs. These information sets must include data such as provider names, contact information, and specialties; Medicare Advantage prescription drug plans must also provide pharmacy directory data, including the number and type of pharmacies in their networks. All information in these directories must be updated within 30 days of receiving notice of any changes.

MMA File Exchange Currently, states are required to share data files known as the Medicare Modernization Act (MMA) file or State Phasedown file with CMS on a monthly basis to identify all beneficiaries dually eligible for both Medicare and Medicaid, with an option of submitting more frequent files. Under the new rule, CMS will require these files to be submitted on a daily basis.

Key Deadlines The requirements to send ADT notifications in the revised Conditions of Participation will go into effect six months from the date of publication of the rule in the Federal Register. CMS extended this deadline to allow time for facilities to prepare their systems for dissemination of these notifications.

Information regarding attestations for information blocking is expected to begin being posted publicly in late 2020. CMS will use the attestations from the EHR reporting period in 2019 for the first round, and then update the public site for each subsequent program year, with the 30-day preview period before public release.

Payers will be required to implement the patient access API requirements outlined above by January 1, 2021.

Provider Directory APIs must be fully implemented by the same date.

The payer-to-payer data exchange requirements must be implemented by January 1, 2022.

States will be required to submit daily MMA files by April 1, 2022.

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2020 Fall Educational Conference & Expo

Renaissance Dallas Hotel • Dallas, TX • October

Submit Your Abstract!

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What would you like to discuss this year?

Submit your abstracts for AMRPA’s 18th Annual Educational Conference & Expo!

AMRPA encourages you to share your knowledge, case studies, and experience in these 6 categories:  Business Operations and Leadership Development  Clinical Care Delivery — A Team Approach  Regulatory, Legislative and Accreditation Matters  Marketing and Relationship Management  New for 2020! Technology, Research and Innovation  Other: Topics Outside the Box

Submit your ideas today!

For more information about how to submit your abstract, visit the AMRPA website: https://amrpa.org/Education/Events/Fall-2020-Call-for-Abstracts For questions about submitting an abstract, contact AMRPA Education Specialist Kirsten Lew at klew@amrpa.org.

#AMRPA 12 AMRPA Magazine / April 2020

Improving the Patient’s Outcomes

A recent personal experience brought the topic of patient outcomes straight to the top of my mind, and inspired me to review some items we should consider in order to ensure good outcomes and an excellent patient experience.

Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.

My father was recently hospitalized, and his acute-care physical therapist (PT) recommended an inpatient rehabilitation stay. Unfortunately, the way she described inpatient rehabilitation and why he would benefit from the stay left my father disinterested. I found myself reflecting on what went wrong in this instance.

First, his providers did not explain what inpatient rehabilitation was and how it differed from other levels of care. Therefore, my father thought of the only comparable thing he knew: a nursing home. Next, his care team was unable to show him what his deficits were, giving him the perception that he would be fine going home without continued care.

We were lucky that he was in fact “too functional” to meet the criteria for an inpatient rehab stay. Had he met the criteria and decided to go home anyway, this could have gone very poorly for my family. This illustrates my ever-present concern regarding the risk of readmissions for patients who do meet the criteria and are admitted to the inpatient rehabilitation setting. If not managed correctly, they are at risk for readmission to the acute hospital.

The patients in the eRehabData® database go home over 74% of the time. Fewer than 15% are discharged to a skilled nursing facility, and approximately 11% go back to acute-care. Currently, inpatient rehabilitation hospitals and units are not penalized for readmission rates that are deemed to be too high. Short-term acute care hospitals are penalized for readmission rates that exceed rates reported from prior periods.

Additionally, research is underway for payment reform that will change the post-acute payment models over the next several years. We have already seen some changes in admission patterns related to bundled payments. It is necessary to do our best with patient discharge planning and preparation to ensure good outcomes once the patient returns home. We also need to ensure post-discharge follow-up is in place to make sure patients are doing the right things and continuing to engage with providers so they will stay at home and continue to improve. Let’s review strategies that will help us meet this goal.

Make sure to complete a thorough risk assessment. Starting with the pre-admission screening, make sure it is clear what comorbidities the patient has, how successful

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the patient was in managing their comorbidities prior to the hospitalization, and type of caregiver support. I am not promoting the idea of screening a patient out based on issues identified at the pre-admission stage. Rather, I think it is important to gather accurate information and pass on the information to others on the rehabilitation side so we can get in front of the problem and create solutions in a timely manner. Likewise, the nursing admission assessment should evaluate the acute-care diagnoses and comorbidities, number of hospitalizations in the past 12 months, and knowledge of clinical risks and complications.

armed and ready to complete their own care. Patient education is critical. We need to address disease processes, including clinical risks and complications, precautions, signs and symptoms, and what to do about them. We need to prepare a medication administration schedule that can be transitioned to the patient or caregiver. Education and return demonstration are necessary.

Patient education is not something that should be done the day before admission. Rather, patient education should be scheduled throughout the stay and topics should be repeated.

An understanding of the patient’s demographics, medical and social history, medication management abilities, and baseline health literacy is also necessary. It is also important to identify and consider social components of care management such as transportation, food, and hydration sources. Between the nurses and case managers, this information should be garnered during the admission assessments.

Promote self-management by creating an individualized care management process that addresses medical conditions, the home environment, social history and patient literacy. A nurse educator recently told me that her greatest frustration is how task-oriented her nurses seem to be. If you feel similarly, it is critical that you add items to the nurse’s daily task list to address patient education on the identification of disease process and medication management.

Eliminate risks of re-admission by ensuring medication reconciliations are completed at admission and discharge. Polypharmacy issues stand in the way of compliance with taking and maintaining a regular drug regimen. As I recently experienced, one of the scariest parts of bringing a loved one home is concerns over giving the current medications, at the correct time, in the correct dosage. Regular follow-up with the patient’s primary care physician is also important.

Transition planning is another key consideration for the patient experience, and information exchange is important. Make sure to review discharge instructions with the patient and caregiver and pass along information to other post-acute providers to ensure continuity of care. From a practical aspect, make sure you have established a network with downstream providers so information exchange is seamless. Community programs can help keep patients plugged in and progressing with their own management.

A study completed at the Dartmouth Institute in 2013 identified five primary reasons for hospital readmissions: 1. Patients do not fully understand what is wrong with them.

2. Patients may be confused about which medications to take and when they are to be taken.

3. Hospitals do not provide the patient or other caregivers with important information or test results.

4. Patients do not schedule a follow-up appointment with their doctor.

5. Family members lack the proper knowledge to provide adequate care.

Make sure you are staying connected with patients after they discharge. Follow-up calls are beneficial at 72 hours, the end of the first week and 30 days post-discharge to answer questions and ensure patients are getting what they need and following your recommendations.

This emphasizes the importance of employing ideal care management strategies so our patients and caregivers are

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There are ways to ensure that you have ample time with patients to address all these care management strategies. The most important way to do this is to capture the correct case-mix group. The assignment is based on the reason for admission, the functional assessment, and the proper capture of comorbidities. Use your time in a meaningful way. Ideal goal setting and family involvement are crucial. All these factors work together to ensure good outcomes and the best possible patient experience.

AMRPA Submits Comments on U.S. News Proposed Ranking Methodology for Rehabilitation Hospitals In March 2020, the American Medical Rehabilitation Providers Association (AMRPA) provided comments and recommendations to U.S. News in response to its previously released proposed ranking methodology for rehabilitation hospitals.

Kate A. Beller, JD, AMRPA Executive Vice President for Policy Development and Government Relations

As background, U.S. News announced in early 2019 that it would shift from relying solely on expert opinion in its rehabilitation hospital rankings and incorporate certain types of objective data in its methodology. The revised rankings will initially focus on what U.S. News views as “high acuity” rehabilitation care. AMRPA engaged extensively with U.S. News in its year-long assessment of weights and measures to be included in the methodology, such as accreditation-related data and outcomes measures. In January 2020, U.S. News unveiled its proposed methodology, which included the following scores: Expert opinion (50%) Select Outcomes-Based Measures on IRF Compare (20%) Volume Conditions for Stroke, TBI and TSCI as reported on IRF Compare (10%) Certain Patient Services Reported on the American Hospital Association Annual Survey (6%) Certain Advanced Technologies Reported on the American Hospital Association Annual Survey (6%) Select Patient Safety Process Measures Reported on IRF Compare (5%) Designation as a NIDILRR Model System for SCI, TBI or Burns (2%) CARF International Accreditation (1%) A full summary of AMRPA’s engagement with U.S. News and a comprehensive overview of U.S. News’ proposed ranking methodology can be found in our February 2020 edition.

In addition to providing comments specific to the 2020-2021 ranking year, AMRPA also used the comment opportunity to recommend refinements in future performance years, such as the potential move to diagnostic-specific rankings. Our full comment letter is copied below, and AMRPA thanks all members who provided critical input and recommendations as part of this process.

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March 19, 2020 SUBMITTED ELECTRONICALLY Mr. Ben Harder Managing Editor and Chief of Health Analysis U.S. News & World Report 1050 Thomas Jefferson St. NW Washington, DC 20007 Re: U.S. News Proposed 2020-2021 Rehabilitation Hospital Ranking Methodology Dear Mr. Harder, On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we appreciate the opportunity to provide comments and recommendations on U.S. News’ proposed methodology for the 2020-2021 rehabilitation hospital rankings. AMRPA is the national voluntary trade association representing more than 650 inpatient rehabilitation hospitals and units (IRH/Us).

Our members have actively engaged with U.S. News with respect to its rehabilitation rankings, both in the context of submitting physician survey data to help U.S. News calculate its expert opinion score and providing input to the U.S. News and Research Triangle Institute (RTI) team as changes have been considered to the rankings methodology over the course of the last year.

AMRPA recognizes that many inpatient rehabilitation patients and their families utilize the U.S. News rankings as part of their decision regarding treatment, and we applaud U.S. News for engaging with provider stakeholders regarding the appropriateness of the inputs and respective weights that will be utilized in the 2020-2021 methodology. In general, AMRPA supports U.S. News’ broader efforts to shift from a ranking methodology that relies exclusively on expert opinion to one that also utilizes objective datasets. We very much appreciate the incorporation of some of the concepts and measures identified by AMRPA members in our prior discussions with the U.S. News and RTI team (e.g., the inclusion of stroke in the condition volume measure and recognition of CARF Accreditation) in the proposed methodology. At the same time, we have concerns about the relevance of some of the measures that U.S. News proposes to use for the purposes of rehabilitation hospital rankings, as well as the fact that numerous measures come from a dataset (Inpatient Rehabilitation Facility (IRF) Compare) that does not capture a hospital’s often-significant non-Medicare patient services. We appreciate your consideration of these issues, and AMRPA stands ready to work with U.S. News to ensure it uses a representative and effective methodology for both 2020-2021 and future performance years.

2020-2021 Proposed Methodology Measures – Expert Opinion Overall, AMRPA supports U.S. News’ efforts to incorporate more objective and hospital-reported data into its methodology, rather than continue to assign 100% of a hospital’s score based on the reputational measure. However, in light of the significant changes being proposed to the methodology and the lack of an all-payer data source (discussed in the following section), AMRPA recommends that U.S. News implement a more gradual transition with respect to the expert opinion weight. We also recommend that U.S. News assess the methodology internally by testing it with expert opinion set at several different weights to identify the most logical reputational weight.

Furthermore, as U.S. News makes large-scale changes to its methodology, AMRPA urges U.S. News to provide more information on the way in which the expert opinion data are captured through survey data. We understand that a hospital’s expert opinion score will continue to be based on the average number of nominations from the three most recent annual surveys of board-certified physiatrists conducted for the Best Hospitals rankings. Physicians may receive a survey if they are listed in the Doximity Masterfile; physicians who use a Doximity service receive the survey electronically, while a random sample of those physicians who do not use a Doximity service receive a survey by mail. AMRPA has concerns that this approach has at times yielded a low number of respondents, and we therefore ask U.S. News to publish the number of the

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expert opinion survey respondents to better inform patients and hospitals. We note, for example, that 35 hospitals were designated as “High Performing in Adult Rehabilitation” in 2019 for being recommended by 1-5% of the survey respondents.

Given the number of survey respondents is relatively small, it is unclear what 1-5% means in terms of number of rehabilitation specialists that recommended a facility. This information would greatly assist AMRPA members as we assess how the expert opinion score is incorporated into the methodology in future years. Relatedly, AMRPA welcomes the opportunity to discuss ways to increase the number of responsive physician surveyors (for example, potential collaboration between U.S. News and the American Academy of Physical Medicine and Rehabilitation (AAPM&R)).

2020-2021 Proposed Methodology Measures – Condition Volume Measures As an overarching issue, AMRPA has concerns with U.S. News’ decision to capture patient volume for certain conditions from the IRF Compare dataset. As the U.S. News and RTI team is wellaware, IRF Compare data only reflects the hospital’s Medicare patient population and is therefore an inaccurate indicator of the overall patient volume for the specified conditions. This is especially problematic for hospitals with disproportionately high numbers of non-Medicare patients, such as hospitals that have specialized in treating young (non-Medicare) traumatic brain injury (TBI) patients. While we appreciate that U.S. News is looking to address these issues by working to incorporate all-payer data in future ranking years, we urge U.S. News to explore other ways of capturing non-Medicare patients for the specified conditions sooner, and recommend a delay in publically presenting the rankings using this new method until a more truly representative assessment of hospital quality for the care of complex patients is achievable On a more granular level, AMRPA supports U.S. News’ decision to include stroke as one of the conditions that will be captured in the condition volume measures. AMRPA members appreciated the chance to advocate for the inclusion of stroke in the methodology in prior discussions with U.S. News, and they support U.S. News’ findings that stroke – along with traumatic spinal cord injury (TSCI) and TBI – is among those conditions that “are considered complex or difficult to treat in a rehabilitation setting” and will therefore be captured in the 2020-2021 rankings methodology. AMRPA also appreciates that each condition will be separately weighted, as we previously raised concern that the volume for one of the three conditions does not necessarily reflect the quality of care provided by that hospital for another condition (e.g., TBI volume does not necessarily reflect the hospital’s experience with caring for patients with TSCI). We urge U.S. News to consider highlighting the different volume totals for the three conditions in the summary of the hospital’s rankings (or elsewhere) to ensure a patient is aware of the volume information specifically for TBI, TSCI, and stroke, as well as to note that these totals only represent Medicare patients.

Finally, and as a broader policy issue, AMRPA urges U.S. News to move beyond a rankings system that more broadly captures hospitals’ performance with respect to several high acuity

conditions, and instead develop a diagnostic-based rankings system. AMRPA believes that the current rankings system may not appropriately guide patients based on their specific condition and clinical circumstance, and would be willing to engage with U.S. News as it considers condition-specific rankings in the future.

AMRPA believes the rankings will be more useful to patients if they provide more granular information on a broader number of conditions and services, such as hospitals’ experience with oncology rehabilitation patients and transplant patients.

2020-2021 Proposed Methodology Measures – Outcomes Measures U.S. News proposes to base 20% of a hospital’s ranking on three outcomes measures currently available on IRF Compare – potentially avoidable 30-day hospital readmission after IRF discharge, potentially avoidable readmissions during rehabilitation care, and successful discharge to home and community. We note, however, that these measures are different across the post-acute care Compare sites (such as IRF and LTCH Compare), specifically with respect to the data included in the denominator. For these reasons, AMRPA urges U.S. News to consider a different methodology and ranking system for other hospitals (such as LTCHs) to ensure that all ranked hospitals are fairly and equally assessed with respect to their outcomes measures. Given the measures on LTCH Compare include all patients and IRF Compare only includes Medicare Parts A and C, LTCHs could have an advantage over rehabilitation hospitals that treat low-proportions of Medicare patients. This issue is discussed in greater depth in our comments specific to U.S. News’ missing data adjustment methodology.

Additionally, AMRPA has tracked the significant changes that the Centers for Medicare and Medicaid Services (CMS) has implemented with respect to how these outcomes measures are reported on IRF Compare, which has impacted how a hospital’s performance category is applied. AMRPA therefore urges U.S. News to utilize risk-adjusted rates instead of the performance categories assigned to each provider based on their performance on these measures (better than, same as, or worse than the national average) and continually assess whether CMS’ methodological approach warrants these measures’ continued inclusion in the rankings methodology.

Furthermore, AMRPA believes U.S. News and RTI should consider the inclusion of two other outcome based measures available on IRF Compare for the 2020-2021 rankings: (1) rate of new or worsened pressure ulcers; and (2) percentage of patients with one or more fall with major injury.

Lastly, AMRPA notes that improvement in function is arguably the most important “outcome” measure in assessing the quality of inpatient rehabilitation care. While we understand that this data is not currently captured in IRF Compare, we urge U.S. News to consider adding the percentage of patients whose functional abilities were assessed data (from IRF Compare) into the 2020-2021 ranking methodology to capture at least some function-related data in the rankings. Furthermore, given the importance of measuring functional improvement in the context of rehabilitation hospital rankings, we ask U.S. News to consider

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other methods of capturing this data (for example, through IRF Patient Assessment Instrument (IRF-PAI) data included in all-payer registries) in a properly risk-adjusted manner in future ranking years.

2020-2021 Proposed Methodology Measures – Process Measures U.S. News outlines two process measures from IRF Compare to be included in the new methodology – (1) influenza vaccinations – healthcare personnel; and (2) influenza vaccinations – patients.

U.S. news has acknowledged that the influenza vaccinations – healthcare personnel measure is being retired by CMS but that “such data is strongly correlated with outcomes and other measures of quality.” We disagree, noting that CMS asserted directly in the FY 2019 IRF Prospective Payments System (PPS) Final Rule that “measure performance among IRFs is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made.” There would be no additional value in including this measure for a single year, based on CMS’ own reasoning for removal from the IRF Quality Reporting Program (QRP), in the rehabilitation methodology, particularly since the last reported data would be from the 20172018 influenza season.

2020-2021 Proposed Methodology Measures – Patient Services U.S. News proposes that 6% of a hospital’s score would reflect whether certain patient services are available at the hospital, within the health system, or via a partnership, based on the hospital’s response on the American Hospital Association (AHA) annual survey. AMRPA understands that U.S. News has limited sources through which it can verify this information, and in deciding to use the AHA Annual Survey as a dataset, U.S. News is forced to rely on the specific patient services included on the survey. However, AMRPA believes that there should be a number of additional patient services included in U.S. News’ list – such as adaptive seating and power wheelchair clinics, driving education and adaptive sports. AMRPA therefore recommends U.S. News to consider other ways to capture this data in future performance years, such as incorporating self-reported data for certain services and technologies, or supporting future efforts to create a survey more specific to the rehabilitation field.

2020-2021 Proposed Methodology Measures – Accreditation AMRPA supports U.S. News’ proposal to incorporate accreditation into its rankings and appreciated the opportunity to discuss the importance of CARF International accreditation in prior discussion with U.S. News. Consistent with those discussions, AMRPA urges U.S. News to additionally consider condition-specific accreditation (such as recognition of hospitals with a CARF International Spinal Cord Specialty Program) and include that data in the accreditation measure.

Additionally, we urge U.S. News to capture this data from CARF International itself, rather than through an intermediary source (as U.S. News proposes to do through the use of AHA Annual Survey data). AMRPA is aware that CARF International has questioned the accuracy of how this data is reported on AHA Annual Surveys,

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and would be willing to work with U.S. News to provide the most accurate and current information.

AMRPA also recommends that U.S. News incorporate the Joint Commission’s disease-specific certifications in addition to CARF accreditation. We believe this would complement our aforementioned recommendation that U.S. News explore diagnostic-based ranking systems Further, AMRPA also agrees with U.S. News’ proposal to include National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) model system grant recipient status in the ranking methodology. We also suggest that additional methods for determining measures for the research and training activities of a hospital be developed in future versions of the survey.

2020-2021 Proposed Methodology Process – Missing Data Adjustment In addition to our comments on the specific measures and weights that are included in the proposed methodology, AMRPA also seeks clarity on how U.S. News plans to account for hospitals that are missing certain data (such as IRF Compare data). As we noted in our comments on the Outcomes measures, AMRPA believes it is imperative that hospitals are compared to each other based on identical datasets, and that hospitals are not advantaged (or disadvantaged) through adjustments that are made to account for missing data. AMRPA therefore seeks greater information on how other measures in the methodology will be “adjusted upward” for those hospitals that do not have IRF Compare data. We have concerns that this approach could result in a measure – such as expert opinion – carrying greater weight for certain hospitals, which could in turn create concerns with the reliability and consistency of the rankings produced through U.S. News’ methodology. *** AMRPA greatly appreciates the opportunity to provide input on U.S. News’ proposed methodology for 2020-2021, and also looks forward to serving as a resource as U.S. News contemplates further changes in future performance years. We are eager to provide any technical assistance or further information on our recommendations and look forward to continuing to collaborate on this important endeavor. If you have any questions, please do not hesitate to reach out to Kate Beller, AMRPA Executive Vice President for Policy Development and Government Relations (202-207-1132, kbeller@amrpa.org) or Jonathan Gold, Director of Government Relations & Regulatory Counsel (202-860-1004, jgold@amrpa.org).

Sincerely,

Robert Krug, MD Board Chair, AMRPA President and Executive Medical Director, Mount Sinai Rehabilitation Hospital

AMRPA Responds to Medicare Advantage Advanced Notice Editor’s Note: On March 6, 2020, AMRPA responded to the Centers for Medicare and Medicaid Services (CMS) Advanced Notice for Medicare Advantage plan year 2021. The following is an abbreviated version of those comments.

Dear Administrator Verma, On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we are submitting this letter regarding the proposed updates to the Medicare Advantage (MA) Part C program through the 2021 Advance Notice released by the Centers for Medicare and Medicaid Services (CMS). Our comments focus on CMS’ request for comment on implementing prior authorization-related measures in the MA Star Ratings Program as well as AMRPA’s ongoing and pressing concerns about practices of MA organizations that restrict access to needed care, resulting in patient harm and increased cost to the Medicare program.

AMRPA is pleased to see that CMS is seeking ways to hold MA plans accountable for prior authorization practices through the MA Star Ratings program. The remainder of this letter will summarize providers’ and patients’ troubling experiences with MA plans pertaining to discharges from acute-care hospitals to PAC settings. Based on these experiences, AMRPA is providing CMS with recommendations for the approaches it should take to incorporate prior authorization measures in the MA Star Ratings program.

In making its recommendations, AMRPA offers an overarching point that there are serious and fundamental flaws in the rules and oversight for how MA plans handle admissions to PAC settings.

Adding measures to evaluate MA quality as it pertains to prior authorization will provide at best modest relief from the current access challenges facing MA enrollees and improve plans’ compliance with the rules that exist today. Most importantly and as a general principle, however, AMRPA does not think it is appropriate that MA plans be allowed to utilize prior authorization at all when multiple treating and consulting physicians have attested to the appropriateness for a hospital admission, which is the case for most MA enrollees seeking admission to an IRH/U. In addition, the current regulatory timeframes – allowing 72 hours or more for a prior authorization decision and appeal – is wholly inconsistent with the 24/7 operation of hospitals and the intensive level of care needed for most IRH/U patients. AMRPA urges adoption of timeframes that better reflect the urgency of these PAC placement decisions for beneficiaries, as this type of action will provide more meaningful relief to patients facing access issues caused by current prior authorization practices.

Therefore, while some additional MA Star Ratings measures pertaining to prior authorization may provide some incremental improvement in the MA program, in no way will this adequately address the underlying defects in the MA program that routinely lead to Medicare beneficiaries being denied access to essential post-acute care. We welcome the opportunity to further engage with CMS on this overarching programmatic issue.

MA Plans Tactics for Post-Acute Care Admissions Most typically, a patient seeking admission to an IRH/U is awaiting discharge at an acute-care hospital. When clinicians screen acute-care Medicare patients for post-acute placement, they must follow very specific Medicare guidelines to determine whether the patient is appropriate for an IRH/U.1 When screening indicates the patient is appropriate for IRH/U care, at least

1

2 C.F.R. § 412.622(a). Among other requirements, to be covered in an IRH/U, the patient must need an interdisciplinary approach to care and be stable enough at 4 admission to participate in intensive rehabilitation. There must also be a “reasonable expectation” that the patient will need multidisciplinary therapy, intensive rehabilitation, and supervision by a rehabilitation physician. The requirement for multidisciplinary therapy must include physical or occupational therapy. Intensive rehabilitation is defined as three hours per day, five days per week (or 15 hours per week). The therapy must be reasonably likely to result in measurable, practical improvement to the patient’s functional capacity or adaptation to impairments. The rehabilitation physician must see the patient at least three times per week. Medicare coverage may not be denied based on treatment norms or rote “rules of thumb.”

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one physician with specialized training and experience in rehabilitation must concur, but in actuality there are usually multiple physicians involved and in agreement about the referral.

This mandated Medicare process already amounts to a selfadministered prior authorization process which – in contrast to the process used by MA plans – is administered by clinicians who are appropriately trained and have actually seen the patient in question.

The first defect in the MA prior authorization process is that plans take up to 72 hours – which does not include weekends – to make an initial organization determination. This is wholly unacceptable and, practically speaking, means that a patient ready for discharge on Thursday may be required to remain in the acute-care hospital five additional days before a determination is made on Tuesday, without running afoul of Medicare rules.

Not only does this delay subject the patient to additional risks, such as for hospital-acquired infections, and force them to incur additional costs while waiting in the acute-care hospital, the delay in receiving therapeutic intervention at the IRH/U often has meaningful negative and lasting impacts on the patient’s recovery and overall outcomes.

Even once an initial determination has been reached, the frustrations for patients and providers usually continue because a very high rate of requests for IRH/U admission are initially denied.

This is largely due to the fact that MA plans utilize proprietary decision tools such as Milliman and InterQual – guidelines that reportedly conflict with Medicare IRH/U coverage criteria in spite of the aforementioned requirements that MA enrollees receive the same benefits as those in the FFS program. Plans’ use of these decision tools seem to drive admissions to lower-acuity settings, such as nursing homes and homecare, regardless of a patient’s appropriateness for inpatient rehabilitation. Most importantly, these proprietary guidelines do not follow Medicare coverage guidelines, representing a violation of the MA enrollees’ right to the same benefits covered under traditional Medicare.2 Further, MA plans will often offer a “peer-to-peer” physician discussion before issuing the final organization determination.

Providers are constantly disappointed by the lack of relevant experience offered by the MA plan physician reviewer, as well as the burden with participating in these calls. Providers report that normally the Medical Director or other MA physician representative discussing the case with the provider has no experience with PAC or rehabilitation. Beyond the lack of specialized training, physician reviewers often have little understanding of the Medicare coverage criteria for PAC, and sometimes cite erroneous standards for IRH/U admissions.

Further, the MA plans usually offer limited windows for the peer-to-peer, with little advance notice, requiring physicians to rearrange their care for patients at the last minute to participate in a call that is rarely fruitful due to the aforementioned defects.

Despite the 24/7 operation and treatment of patients in hospitals, the peer-to-peers are offered only during business hours.

2

Id. § 422.101(b).

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As CMS knows, beneficiaries are also entitled to an appeal of the initial organization determination. However, providers and enrollees are equally stymied by these appeals because they contain most of the same shortcomings as the initial determinations. It is important to contextualize that once the initial determination has been made, the patient in question has been waiting in an acute-care hospital for three to five days. The MA plan then usually takes up to another 72 hours to render a reconsideration decision. This means the patient and hospitals are faced with the choice of accepting the MA plan’s lower level of care against physician advice, or unnecessarily holding the patient for another three days in the acute-care hospital. This is simply an untenable position that puts the MA organization’s interests before that of the patient. Similarly, hospitals report that just like the initial determination, the MA representative conducting the reconsideration requests often lack training or experience in PAC, and render affirmations of the initial decision based on faulty coverage and medical premises.

Technically speaking, MA enrollees are entitled to additional levels of review beyond the reconsideration stage. However, due to the unacceptable delays in receiving decisions from MA plans, it is practically impossible for a patient who has been waiting for discharge for a week or more to remain in the acute-care hospital to pursue further levels of appeal. The interests of the patient dictate that the patient will at least initially need to move to a lower level of care, where they may or may not have the resources to continue to appeal their case. Even if a favorable decision can be reached at the second level of appeal, it is often no longer in the best interest of the patient to once again disrupt their recovery with a transfer to the IRH/U from the lower acuity setting.

In addition to the aforementioned practices, hospitals have noted a number of other abuses by MA plans in recent years.

These include informing beneficiaries that the IRH/U is not a covered benefit, that they are not entitled to appeal the initial determination or reconsideration, and denying IRH/U physicians ability to participate in the peer-to-peer or reconsideration because they “lack standing” in the case. In addition, for those few MA enrollees who do get admitted to IRH/Us, MA plans are putting up roadblocks to discharge of the patient from the IRH/U, possibly in an attempt to frustrate the hospital and discourage future admissions.

In all, current MA approach to prior authorization is completely devoid of practices that are patient-centered or ensure the treating clinicians have the ability to help their patients receive the care they need. Incentivizing MA plans to improve their performance relative to current regulations could be a positive first step toward more comprehensive reform of the managed care prior authorization process.

MA Star Rating Measures to Provide Accountability for Prior Authorization Practices The overarching principle that should guide CMS’ approach to oversight of MA plans is to ensure that patients are receiving

the right care at the right time and in the right setting. This means that CMS should measure two overall categories of prior authorization performance: 1) timeliness and 2) accuracy.

Therefore, while patient feedback should remain an important component of MA Star Ratings, provider feedback on MA plans should also be included to a greater degree than currently exists, along with independent reviews conducted by CMS. Accountability for Timeliness As discussed earlier, a patient in an acute-care hospital should not be waiting more than a few hours for a decision on their discharge disposition. Currently, Star Ratings account only for timely appeals. For many patients seeking PAC placement, by the time they have reached the appeal stage, it is already too late for clinically appropriate PAC placement. Therefore, MA plans should be incentivized to provide the initial authorization determinations as timely as possible, especially for vulnerable hospitalized patients.

To accomplish this, MA plans should be required to track and report the time it takes for a decision to be made on a prior authorization request for a patient in an acute-care setting. The scoring of this measure should tier median response times, so that MA plans that typically provide responses in under 12 hours (while factoring in all clinical/environmental patient needs) receive the highest score, those that typically respond within 24 hours receive the second highest score, and plans with response times typically longer than 24 hours receive the lowest rating.

CMS should also hold MA plans accountable by tracking the number of avoidable days their beneficiaries spend in acute-care hospitals. Avoidable days metrics are already tracked by hospitals and CMS, and if incorporated into MA Star Ratings, would encourage MA plans to move as quickly as possible to discharge the patient to the appropriate site of care. CMS should use an objective scoring mechanism to provide MA plans with the lowest number of avoidable days the highest Star Rating score, and those with a high number of avoidable days should receive a significant reduction in their Star Ratings.

Recommendations: 1. MA plans should be required to track and report the time it takes for the plan to make an initial organizational decision.

MA plans that make decisions in 12 hours or less should receive the highest Star Ratings score.

2. CMS should incorporate avoidable hospital days into the MA Star Rating program to incentivize rapid determinations for hospitalized patients.

Accountability for Accuracy It is self-evident that timeliness is only one aspect of a properly conducted authorization request. It is equally imperative, if not more so, that an MA plan have a process in place that reaches the appropriate clinical decision about the patient’s admission.

While that decision is always best left to the treating or consulting physician, when MA plans nonetheless choose to second-guess physician decisions, they should be incentivized to ensure they have an efficient way to employ the requisite expertise to review

the case. Currently, MA Star Ratings only account for accuracy of appeals. As stated earlier, some patients are unable to remain in the acute-care hospital and appeal their case, and even if they do, they’ve been harmed by having to do so. Therefore, it is important that CMS also account for accuracy of initial determinations, and not appeals alone.

First and foremost, the MA plan should be asked to demonstrate its initial decisions are reached in accordance with Medicare coverage guidelines. CMS should audit plans’ initial determinations, separate and apart from the current independent review entity processes, to determine whether the plan is relying on Medicare coverage guidelines and whether it utilized reviewers with relevant medical expertise. Plans that rely on inappropriate proprietary guidelines that do not conform with Medicare rules, or do not have properly trained reviewers, should receive the lowest score in this rating. Plans that rely on Medicare coverage guidelines, but inappropriately deny care nonetheless, or do not have properly qualified personnel, should also receive a subpar score. The audits should be able to objectively verify that the plan consistently made decisions using highly qualified staff who conform to the Medicare coverage guidelines in order for the plan to receive an above average score. Independent practicing physicians assigned to cases within their field of expertise should conduct these audits.

Another way that CMS could evaluate MA plans’ prior authorization processes is to track the total number of appeals initiated by physicians, regardless of outcome. It is unsurprising that an MA plan often affirms its initial determination at reconsideration, even though the plan is required to use different personnel for the appeal. Moreover, for the aforementioned reasons, many acute-care patient cases cannot proceed to the second level of appeal. Therefore, an effective way to track the accuracy of MA plans’ determinations would be to evaluate how often a treating physician disagrees with plans’ initial determinations. It should be telling to CMS when specialized physicians disagree strongly enough with an MA plan to pursue an appeal for a patient. It can be reasonably concluded that MA plans with higher rates of appeals from physicians are doing a poor job of making proper initial decisions for patients.

Beyond patient experience and CMS audits, the MA Star Ratings should also take into account providers’ perspective on plans.

After all, it is the providers who are the specialists treating the patient and in the best position to judge the appropriateness of MA plans’ decisions. CMS should develop a survey of providers that takes into account several aspects of MA plan performance.

The areas surveyed should include whether the MA plan made decisions in a timeframe consistent with the patient’s medical condition, whether the MA plan had 24/7 availability of medical personnel to match the operations of hospitals, whether the MA plan made decisions in accordance with sound medical judgement and Medicare coverage rules, and whether the MA plan employs personnel who have appropriate qualifications.

All of these are important factors that not only affect MA enrollees’ access to appropriate care, but would also be difficult for a consumer to discern. Therefore, it is imperative that CMS

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incorporate this provider perspective into the Star Ratings.

Long-term cost is another way to hold MA plans accountable through the Star Ratings program. MA plans may have a financial incentive to deny admission to an IRH/U when the alternative post-acute placement is less expensive in the short-term.

However, when patients receive more intensive rehabilitation in an IRH/U, their improved functional status can lead to less resource use in the long-term.3 This is why CMS needs to add incentives for MA plans to control long-term costs. While it might seem as though the per-capita relationship between the CMS and MA plan already incentivizes cost control, that line of thinking misses several nuances, particularly when looking at the longer-term picture.

First, data suggests that high-cost patients leave MA plans and enroll in traditional Medicare at a substantial rate.4,5 In addition, studies show IRH/Us actually extend life expectancy relative to lower intensity settings.6 Armed with this information, an MA plan can save money in the short-term by denying more intensive post-acute care, and not be on the hook for the higher-long term cost for many of those patients in light of the rate in which these patients leave their plans as well as their shorter life expectancy. Accordingly, CMS should track and rate MA plans on cost-measures such as Medicare Spend Per Beneficiary, and that tracking should extend well beyond the plan year to incorporate rolling updates of beneficiaries who were once or are still are enrolled in the MA plan. Holding MA plans accountable for long-term costs will incentivize plans taking the best action for the patient in the long-term and focus less on short-term financial implications.

Finally, CMS requests information about how it could evaluate MA plans on how well the plan operates automated or electronic prior authorization. AMRPA considers it highly important that plans continue to make transferring medical information and other communications as seamless as possible. For many providers, electronic prior authorization offers a convenient and time-saving option for communication with the MA plan.

However, due to the wide range of electronic health record systems and interoperability issues that still exist in the field, MA plans should also provide alternative options for communicating with hospitals. AMRPA recommends that CMS incorporate a question in its provider survey that invites feedback on the availability of electronic and other convenient means to communicate with the MA plan. This would ensure that MA plans are not incentivized to use only one method, but rather to make it as easy as possible for providers to transmit information.

As far as automation goes, AMRPA has serious concerns about any sort of automated process that does not incorporate expert medical review. The disposition to PAC can often be

medically complex and nuanced. AMRPA has explained to CMS how certain decision-making tools currently in use lead to improper placements. Any sort of automation that an MA plan is permitted to operate should be thoroughly vetted by CMS and strictly adhere to Medicare coverage guidelines. Given the current concerns with automation, we do not recommend CMS implement any measures on automation at this time, and instead focus on aligning MA plans’ decisions with Medicare coverage criteria.

Recommendations: 1. C MS should audit plans’ initial determinations to determine whether the plan is relying on Medicare coverage guidelines and whether it utilized reviewers with adequate medical expertise. The findings of these audits should be scored and incorporated into the MA Star Ratings system.

2. C MS should score MA plans based on the number of times physicians appeal its initial determinations. The more often practicing physicians disagree with plans’ determinations, the lower the MA plans’ score should be.

3. C MS should incorporate provider surveys into the MA Star Ratings. Providers should be surveyed on whether the MA plan made decisions in an appropriate timeframe, whether the plan had 24/7 availability of medical personnel, whether the MA plan made decisions in accordance with sound medical judgement and Medicare coverage rules, and whether the MA plan employs personnel who have appropriate qualifications.

4.C MS should hold MA plans accountable for long-term cost and incorporate this into the Star Ratings. This should include tracking utilization by patients beyond just the plan year and even for patients who have left the plan. *** AMRPA is committed to continuing to work with CMS to enhance oversight of MA plans and ensure access to critical services for Medicare beneficiaries. If you have any questions about AMRPA’s recommendations, please contact AMRPA’s Director of Government Relations and Regulatory Counsel, Jonathan Gold, JD, at jgold@amrpa.org or 202-860-1004.

Sincerely,

Robert Krug, MD, Board Chair, AMRPA President and Executive Medical Director, Mount Sinai Rehabilitation Hospital

ee DOBSON DAVANZO & ASSOCIATES, ASSESSMENT OF PATIENT OUTCOMES OF REHABILITATIVE CARE PROVIDED IN INPATIENT REHABILITATION FACILITIES S (IRFS) AND AFTER DISCHARGE (July 2014).

4 E.g., Momotazur Rahman et al., High-Cost Patients Had Substantial Rates of Leaving Medicare Advantage and Joining Traditional Medicare, 34(10) HEALTH AFF. 1675, 1679-80 (Oct. 2015).

5 Government Accountability Office, CMS Should Use Data on Disenrollment and Beneficiary Health Status to Strengthen Oversight, GAO-17-393 (April, 2017).

6 Momotazur Rahman et al..

3

22 AMRPA Magazine / April 2020

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03263 AMRPA Magazine / April 2020 23

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24 AMRPA Magazine / April 2020

AMRPA Represents the Power of Medical Rehabilitation at Brain Injury Awareness Day 2020 Brain injury is a significant cause of death and disability in America. Each year more than 3.5 million children and adults sustain an acquired brain injury, of which approximately 2.5 million are traumatic brain injuries (TBI). Of the yearly 2.5 million TBIs, 280,000 are hospitalized and 50,000 lead to death. It is estimated that there are 5.3 million Americans living with a TBI-related disability.

March was Brain Injury Awareness Month, and on March 4, AMRPA staff represented the association at Brain Injury Awareness Day on Capitol Hill. This important annual event, hosted by the Brain Injury Association of America and the Capitol Hill Brain Injury Task Force, provides attendees the opportunity to educate elected officials on the prevalence and impact of brain injury and the importance of continued federal funding for programs such as the Centers for Disease Control and Prevention (CDC) Traumatic Brain Injury programs and the Federal TBI State Grant Program. The event included an awareness fair, a briefing with elected officials and stakeholders and a reception, providing an excellent opportunity for AMRPA to promote the important role of inpatient rehabilitation for many brain injury patients.

The theme for the 2020 Brain Injury Awareness Day was #ChangeYourMind. The Change Your Mind campaign “provides a platform for educating the general public about the incidence of brain injury and the needs of people with brain injuries and their families.

The campaign also lends itself to outreach within the brain injury community to destigmatize the injury, empower those who have survived, and promote the many types of support that are available.�

Numerous attendees visited the AMRPA table to discuss the profound impact medical rehabilitation has had on their lives and/or the lives of their loved ones. Additionally, several members of the general public were interested to learn how inpatient rehabilitation hospitals and units are distinct from other post-acute care settings, and staff was able to engage in collaborative discussion about the value and power of medical rehabilitation. Several other stakeholders, including the Administration for Community Living, American Physical Therapy Association, American Occupational Therapy Association, and the CDC Injury Center were present at the fair as well, allowing for further networking and collaboration to address brain injuries.

AMRPA Magazine / April 2020 25

Following the awareness fair, staff attended the “Improving Function After Brain Injury Leads to Greater Life Participation” briefing hosted by the Congressional Brain Injury Task Force Chairs Reps. Bill Pascrell (D-NJ) and Don Bacon (R-NE). The briefing included speakers from Success Rehabilitation, the CDC’s National Center for Injury Prevention and Control, Maryland Behavioral Health Administration, Abbott Diagnostics, Office of Special Education and Rehabilitative Services, and a patient survivor story. Reps. Pascrell and Bacon also spoke on the importance of brain injury awareness and treatment. *** AMRPA is committed to representing the importance of inpatient rehabilitation units and hospitals at relevant events such as the annual Brain Injury Awareness Day on Capitol Hill. Stay tuned for coverage of future events attended by AMRPA.

JOIN TODAY!

Advocating. Educating. Connecting.

AMRPA: Working Together to To Preserve Preserve Access To Medical Rehabilitation AMRPA: Working Together Access to Medical Rehabilitation Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org

Elizabeth Katsion, AMRPA Member Services Coordinator, ekatsion@amrpa.org, 202-207-1102.

26 AMRPA Magazine / April 2020

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CMS Proposes Three Year Extension of Joint Replacement Model

In February, the Centers for Medicare and Medicaid Services (CMS) proposed changes to the Comprehensive Care for Joint Replacement (CJR) Alternative Payment Model. In addition to an extension of the payment model, there are several key revisions proposed to the program going forward.

Jonathan M. Gold, JD, AMRPA Director of Government Relations & Regulatory Counsel

Highlights:

» »

Outpatient Procedures to be Included in Model Target Pricing and Reconciliation Process Will be Modified

Implementation of the CJR model began in April 2016 and is being run by CMS’ Center for Medicare and Medicaid Innovation (CMMI). This is an episode-of-care model that holds hospitals financially liable for the quality and cost of care following a joint replacement conducted there. The episode begins when a patient is discharged from an acute-care hospital under a diagnosis of major joint replacement of a lower extremity, both with and without major complications. The episode runs for 90 days after discharge and includes all Medicare Part A and Part B spending.

For the initial two years of the model, participation was mandatory for all acute-care hospitals located within 67 metropolitan statistical areas (MSAs) that were selected by CMS. In late 2017, CMS finalized changes that made participation voluntary for 33 of the 67 MSAs, as well as for all rural and low volume providers within the original 67 MSAs. Currently there are about 465 acute-care hospitals participating in the CJR model. As part of this model, CMS has waived the Skilled Nursing Facility (SNF) “three-day rule,” which requires a beneficiary to have been admitted to a hospital for three consecutive days within the 30 days prior to admission to a SNF to be covered by Medicare.

Most notably, CMS is proposing to extend the CJR model for additional three years, until 2023. The proposal would also change the episode definition of the model to incorporate hospital outpatient hip and knee replacements. This change is being made in conjunction with other recent changes from CMS that allows for total knee and hip replacements to be done on an outpatient basis for Medicare patients for the first time. CMS is also extending the waiver of this SNF three-day rule to these patients so that beneficiaries that have a joint replacement on an outpatient basis will have SNF coverage despite not being admitted to the hospital prior to the SNF stay.

CMS has also proposed to change the basis for the target price for the model from three years of claims data to the most recent one year of claims data. According to CMS, this change was precipitated by noticeable cost reductions in joint replacements over recent years, which made three year-old claims data less useful for setting benchmarks. In conjunction with this change, CMS is also eliminating many of the periodic updates it was making to target prices since it will only be using more recent data.

28 AMRPA Magazine / April 2020

To accompany changes to the target pricing, CMS’ proposal would also change the reconciliation process. Currently there are two reconciliation periods, one conducted at two months and one at 14 months after each performance year. Under this proposal, there would be just one reconciliation period, which would occur six months after the performance year. As part of that reconciliation, CMS would also incorporate an additional episode-level risk adjustment status that would be based on a beneficiary’s age and number of conditions.

CMS is also proposing to modify its current cap on gainsharing arrangements with downstream clinicians. Currently, CMS restricts hospitals from gainsharing more than 50 percent of the Medicare allowed amount under the physician fee schedule of items and services furnished to the beneficiary. CMS is proposing to eliminate that 50 percent cap when the gainsharing arrangement is with a physician or group practice for episodes that begin on or after January 1, 2021.

Within the proposed rule, CMS also seeks comment on how it could create a new payment model for joint replacements that are conducted in settings other than hospitals, such as ambulatory surgery centers. CMS says that it would like stakeholder feedback on what entities should be required to participate in the model, including whether physicians or other clinician types should be held financially accountable for the episode of care. The proposed rule also asks whether these additional models should be site neutral, meaning providers would be paid the same whether the procedure is performed at a hospital, ambulatory surgical center, or other site of care.

The proposed rule was published in the Federal Register on February 24, 2020. Comments are due on the proposed rule by April 24, 2020.

AMRPA Magazine / April 2020 29

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30 AMRPA Magazine / April 2020

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PAC Market Analysis Reports Find out where your institution stands with a Market Analysis of Medicare Post-Acute Care (PAC) Referral Patterns, Episode Spending, Performance Measures and Impact of Medicare Bundled Payment Models

Using the most recent two years of Medicare claims data, Dobson DaVanzo & Associates delivers inpatient rehabilitation providers with a general market-level analysis on their facility’s episode spending and key performance metrics across all Medicare discharges. Benchmark your facility against state and national inpatient rehabilitation providers and find out where you stand.

Dobson DaVanzo & Associates can also help you better understand how the Bundled Payment for Care Improvement (BPCI) initiative and the Comprehensive Care for Joint Replacement Payment Model (CJR) are impacting the markets.

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32 AMRPA Magazine / April 2020

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AMRPA & eRehabData ÂŽ Have Your Back

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34 AMRPA Magazine / April 2020