August 2018 • Vol. 21, No.8
ACOs and Post-Acute Care
August 2018 • Vol. 21, No. 8
The official publication of the American Medical Rehabilitation Providers Association (AMRPA)
Table of Contents Letter from the Chair
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Legislative Update
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Recent Developments Impacting DMEPOS
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FIM Essentials for the PPS Coordinator
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MedPAC Issues Annual June Report; Explores Additional Issues Related to PAC PPS and Promoting Use of High-Quality PAC Providers
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Carolyn Zollar, MA, JD AMRPA Executive Vice President for Government Relations and Policy Development
AMRPA Submits Comments on the FY 2019 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Proposed Rule
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Mimi Zhang AMPRA Senior Policy and Research Analyst
AMRPA Submits Letter to CMS Responding to IPPS and LTCH Proposed Rule for Fiscal Year 2019
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Recent Updates to HHS Inspector General Work Plan
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AMRPA Submits Comments to HHS on Ways to Increase Innovation and Investment in the Healthcare Sector
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CMS’ CY 2019 Proposed Rule Includes New Provisions for Home Health Agencies
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CMS Advances Medicare Advantage Demonstration for MIPS Exemption
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CMS Did Not Detect Inappropriate Durable Medical Equipment SNFs Claims, Says OIG
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Study Examines Variation in Role of LTCHs Versus SNFs in Older Adults’ Post-acute Care
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CMS Launches Data Element Library Supporting Interoperability
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Study Evaluates the Effectiveness of Nonsurgical Options to Treat Knee Osteoarthritis
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Report Outlines Ways to Improve Health and Functioning Outcomes for Children with Disabilities
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Hospital-at-Home Care Bundled with a 30-Day Post-Acute Transitional Care Episode was Associated with Better Patient Outcomes
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Latest Research Findings
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Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Manager
Patricia Sullivan AMRPA Senior Editor Lovelyn Robinson AMRPA Researcher and Editor Brian McGowan and Shirley Soda AMRPA Design and Layout
AMRPA Magazine, Volume 21, Number 7 AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA). AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Individuals who are employees of member institutions may subscribe to the magazine for $100 annually. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color. Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Samantha Schwarz, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1132, Email: sschwarz@amrpa.org Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content ©2018 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Kellen Company. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 750, Washington, DC 20045
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AMRPA Magazine / August 2018
Letter from the Chair
Richard Kathrins, PhD, President & CEO, Bacharach Institute for Rehabilitation RKathrins@bacharach.org
ACOs and Post-Acute Care. What impact do hospital-based Accountable Care Organizations (ACO) have on the post-acute care industry? In a recent conversation, Chris Lee, vice president of rehabilitation at Madonna Rehabilitation Hospitals in Nebraska, noted that acute care hospitals haven’t reduced the cost of their own settings but have avoided or reduced the use of downstream providers. His observation was based on the Medicare Payment Advisory Commission (MedPAC) June 2018 report that stated, “We find that, despite the apparent conflict in incentives, hospitals may still want to participate in ACOs because most savings for ACOs to date stem from reductions in the use of post-acute care and not from reductions in [acute] inpatient care (MedPAC, 2018, p. xvii).” MedPAC’s report cited the findings of one study that also found that reduced spending for post-acute care did not reduce the quality of patient care (McWilliams, Gilstrap, Stevenson, Chernew, Huskamp, et al., 2017). The study focused on skilled nursing facilities (SNFs) outcomes defined as mortality and readmissions. Unfortunately, such outcomes as function and quality of life in the community were not addressed. These results were similar to those reported in another study (Muhlestein, Morrison, Saunders, Bleser, McClellan, et al., 2018), which compared data from 2013 to 2016 and found savings were from decreased usage of SNFs, ambulances and durable medical equipment. They further noted that savings were not significant for acute inpatient, home health or hospice, and there was an increase in spending for physician services which included physician outpatient services. The MedPAC report discussed a conflict in incentives for the acute care hospitalled ACO. On face value, one would think that ACOs savings would be found from reducing any type of unnecessary services, such as by avoiding acute care admissions (MedPAC, 2018, p. 230) and readmissions, lab tests or other procedures. In practice, however, hospitals are finding opportunities to maintain their revenue levels. The report suggested that hospitals have an incentive to increase volume in a fee-forservice environment whereas ACOs have an incentive to reduce spending, “…it would appear that the incentives for hospitals and ACOs are in conflict (MedPAC, 2018, p. 230).” Since the hospitals are not reducing cost by reducing acute care spending, they are finding the savings from the post-acute care marketplace. Granted, MedPAC did not specifically address inpatient rehabilitation hospital or unit IRH/Us utilization, yet the impact on the patient’s access to post-acute care may be significant. McWilliams (2017) also indicated that these findings have potential implications for Medicare’s other “value-based" payment and care models, notably the Bundled Payment for Care Improvement (BPCI) initiative. BPCI participants can also use reductions in post-acute utilization as a way of reducing costs. Although MedPAC did not specifically address ACO’s impact on IRH/Us utilization, it is clear that patients’ access to IRH/Us and all post-acute care may be significantly affected by ACOs. The early evidence being presented means we must be ever vigilant advocating for our patients to have access to the critical services that are needed to improve function and quality of life.
REFERENCES McWilliams, J.M., Gilstrap, L.G., Stevenson, D.G., Chernew, M.E., Huskamp, H.A., Grabowski, D.C. (2018). Medicare Accountable Care spending patterns: shifting expenditures associated with savings. JAMA Intern Med, 177 (4), 518-526. doi:10.1001/jamainternmed.2016.9115 Medicare Payment Advisory Commission (2018, June). Report to Congress - Medicare and the Health Care Delivery System. Washington, DC. Retrieved from http:// medpac.gov/docs/default-source/reports/jun18_medpacreporttocongress_sec.pdf?sfvrsn=0. Muhlestein, D.B., Morrison, S.Q., Saunders, R.S., Bleser, W.K., McClellan, M.B., Winfield, L.D. (2018). Medicare Accountable Care spending patterns: shifting expenditures associated with savings. Am J Accountable Care, 6 (1), 11-19. Retrieved from https://ajmc.s3.amazonaws.com/_media/_pdf/03_AJAC_Research_0318_Muhlestein.pdf
AMRPA Magazine / August 2018
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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. Fighting Restrictive Medicare Policies • Challenging Aggressive Contractors We need all IRFs to lend a hand in challenging aggressive Medicare auditors in order to level the playing field, and preserve and enhance patient access to IRF care. 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. 4
AMRPA Magazine / August 2018
Legislative Update
Martha M. Kendrick, Esq., Partner, Akin Gump Strauss Hauer & Feld LLP
Highlights: »»
CMS released the annual home health payment rule that proposes a revamped case-mix payment system.
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CMS proposes to delay the Competitive Bidding Program, and plans a major overhaul of Medicare billing standards for physicians and continues to further expand the use of telehealth.
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Although the Senate has scrapped most of its traditional August Recess, the need to confirm a Supreme Court nominee has likely shifted priorities. President Trump nominated Judge Brett Kavanaugh as the next Supreme Court Justice, in light of Judge Kennedy’s announced retirement; this development may delay plans for consideration of remaining Appropriations bills.
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After House passage of a major opioid package, Senate consideration of its measure will likely occur late summer.
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As polls begin to favor a Democratic surge in the House, Members in both parties plan to recess in August to continue their aggressive re-election campaigns.
Physician Fee Schedule Proposed Rule Lays Out Major Overhaul of Physician Payments On July 12, CMS released its CY 2019 Physician Fee Schedule (PFS) Proposed Rule, and included several policies aimed at streamlining the billing process for physicians by combining four separate levels of documentation requirements, specifically the Evaluation and Management (E&M) level 2 through 5 codes, into one. CMS stated this change would reinforce CMS’ Patients Over Paperwork initiative focused on reducing administrative burden while improving care coordination, health outcomes, and patients’ ability to make decisions about their own care. CMS is also expanding how it pays for remote monitoring and telehealth services in Medicare. Explicitly, the regulation proposes to pay separately for several codes that use technology-based services, such as a virtual patient check-in and reviewing patient submitted video and/or images. These policies would not be subject to the 1834(m) limitations of Medicare telehealth services. CMS is also proposing to pay for six CPT codes that describe interprofessional consultations (CPT codes 994X6, 994X0, 99446, 99447, 99448 and 99449) via a telephone or internet assessment. The agency is also planning to move forward with paying for several chronic care remote physiologic monitoring codes. CMS is also moving forward with implementing the requirements of the Bipartisan Budget Act of 2018 for telehealth services related to beneficiaries with end-stage renal disease (ESRD) receiving home dialysis and beneficiaries with acute stroke effective January 1, 2019. The Bipartisan Budget Act of 2018 also requires payment for services furnished in whole or in part by a therapy assistant to be 85 percent of the applicable Part B payment amount for the service effective January 1, 2022, which requires CMS to establish a new modifier. Therefore, CMS is proposing to establish two new therapy modifiers for use in 2020 – one for PT assistants (PTA) and another for OT assistants (OTA) – when services are furnished in whole or in part by a PTA or OTA. The proposed changes to the Quality Payment Program (QPP) are also focused on the reduction of clinician burden, as well as outcomes, and promoting interoperability of electronic health records (EHRs). CMS proposes to remove the Merit-based Incentive Payment System (MIPS) process-based quality measures that clinicians have voiced are low-value or low-priority, in order to focus on meaningful measures that have a greater impact on health outcomes. The agency is proposing to overhaul the MIPS “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information, as well as align this performance category for clinicians with a new Promoting Interoperability Program for hospitals.
AMRPA Magazine / August 2018
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Finally, CMS included a proposal that would change how Medicare pays for Part B drugs by reducing the wholesale acquisition cost (WAC) add-on payment from 6 percent to 3 percent, effective Jan. 1, 2019. The Trump administration opined that this policy is aimed at curbing excessive drug spending and is a way to align payments and drug acquisition costs, particularly for drugs with high launch prices. Home Health Proposed Payment Rule Includes Revised Payment Reform Model On July 2, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2019 Home Health Prospective Payment System Rate Update and CY 2020 CaseMix Adjustment Methodology Refinements Proposed Rule. CMS projects that Medicare payments to home health agencies (HHAs) will increase by 2.1 percent ($400 million) in 2019, based on the proposed policies. The proposed rule would implement a new Patient-Driven Groupings Model (PDGM), eliminating the use of “therapy thresholds” and changing the unit of payment to 30-day periods of care. Congress directed CMS via the Bipartisan Budget Act of 2018 to change the unit of payment under the HH PPS, from 60-day episodes of care to 30-day periods of care, to be implemented in a budget neutral manner by Jan. 1, 2020. The CY 18 HH PPS proposed a similar model, previously known as the Home Health Groupings Model (HHGM), but CMS chose not to move forward with it due to congressional alternative direction and stakeholder outcry that the model was not budget neutral. According to CMS, the PDGM aims to removes the current incentive to overprovide therapy, and instead is designed to focus on clinical characteristics and other patient information to allow payments to better reflect patients’ needs and characteristics, with the goal of moving more towards a value-based payment system. The proposed rule also makes changes to reduce administrative burdens on physicians, defines remote patient monitoring and proposes to include it as an allowable administrative cost. In addition, CMS released a Request for Information with the proposed rule to welcome feedback on the Medicare program and interoperability. DME Competitive Bidding Program Put on Hold On July 11, CMS released the Calendar Year (CY) 2019 Changes to the End-Stage Renal Disease (ESRD) Prospective Payment System, Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Proposed Rule. CMS proposes significant reforms to the bidding process itself, but signals that the program is likely to lapse for some indeterminate period of time. The existing contracts will expire at the end of 2018, but CMS proposes to keep the payments in place and increase them by the urban Consumer Price Index (CPI) until the agency restarts the bidding program. House Passes Opioid Measure, Awaits Senate Move Congress has spent the last several months developing and advancing legislation to address various aspects of the opioid crisis. On June 22, the House voted overwhelmingly to pass the SUPPORT for Patients and Communities Act (H.R. 6), a bipartisan legislative measure that combines nearly 60 bills previously considered individually by the chamber. While the White House 6
AMRPA Magazine / August 2018
urged the Senate to “swiftly pass” H.R. 6, the Senate is moving ahead on crafting its own opioid package, which could be conferenced with the House bill at a later date. Senate HELP Committee Chair Lamar Alexander (R-TN) is leading efforts to combine bills from the Senate HELP, Judiciary, Finance and Commerce committees into a single package. While Senate Majority Leader Mitch McConnell (R-KY) has not indicated when a floor vote will be held, likely late July, the opioid legislation is a priority for consideration this summer. Appropriations Process Continues On June 25, the Senate voted 86-5 to pass a three-bill minibus combining the Military Construction-VA, Legislative Branch, and Energy-Water appropriations measures. The House passed its own version of the package on June 8 in a 235-129 vote. After several delays, the House Appropriations Committee approved its Fiscal Year 2019 Labor-HHS spending bill on a 30-22 vote after a 13-hour session on July 11. The committee adopted a bipartisan manager’s amendment that shifted funds around within HHS, providing an additional $75 million for Substance Abuse and Mental Health Services Administration (SAMHSA) programs and an additional $50 million for the Centers for Disease Control and Prevention (CDC). Democrats offered more than a dozen amendments related to migrant family separations, and many were adopted by voice vote. The committee also adopted 26-25 an amendment from Rep. Marcy Kaptur (D-OH) that would require HHS to report on drug spending in Medicare and Medicaid. House Labor-HHS Subcommittee Chair Tom Cole (R-OK) stated that he was hopeful that the Labor-HHS bill will be combined with the House Defense appropriations bill (H.R. 6157). Notably, the House Committee does not support moving the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) to the National Institutes of Health (NIH), as proposed in the president’s FY 2019 Budget Request. The House Committee Report also calls on CMS to increase oversight of contractors who are tasked with audit of claims, including Zone Program Integrity Contractors, Medicare Administrative Contractors, and Qualified Independent Contractors. The House Committee encourages MedPAC, in consultation with MACPAC, to prepare a report that examines the relationship between the physician or post-acute care physician and related burdens associated with each provider involved in authorizing patients for home health care services, certifying patient’s needs for diabetic shoes, conducting assessments to admit patients to skilled nursing facilities, and providing the initial certification of patients for hospice care. The Senate Appropriations Committee approved its FY 2019 Labor-HHS spending bill on June 28. As with the House version, the Senate Committee Report does not support moving the NIDILRR to the NIH.
VA Secretary Nomination Moves to Senate Floor On July 10, the Senate Committee on Veterans’ Affairs met to consider the nomination of Robert Wilkie to serve as Secretary of Veterans Affairs. The committee voted to favorably report the nomination to the full Senate, with the exception of Sen. Bernie Sanders (I-VT), who opposed the nomination. Wilkie stated that he would carry out the mandate of newly passed legislation, the VA Mission Act, that calls for expanding private health care for veterans. However, he confirmed that he was not a proponent of privatizing the entire VA health care system. Previously, Wilkie served as Acting VA Secretary when embattled David Shulkin resigned from the position. Association Health Plan Final Rule Released On June 19, the Department of Labor (DOL) released a final rule on association health plans (AHPs) that will allow more employers form AHPs. In addition to industry AHPs, an AHP will also be able to form based on a geographic test. The DOL clarified that existing consumer protections and antidiscrimination protections will continue to apply to AHPs organized under the final rule. Medicaid Program Integrity Initiatives Announced On June 26, CMS announced several new initiatives to improve Medicaid program integrity. These include: emphasizing program integrity in audits of state claims for federal match funds and medical loss ratios; conducting new audits of state beneficiary eligibility determinations; and optimizing state-provided claims and provider data. CMS notes in his announcement that Medicaid spending grew from $456 billion in 2013 to $576 billion in 2016. MedPAC June Report Includes PAC Sector Analysis On June 15, the Medicare Payment Advisory Commission (MedPAC) released its June 2018 Report to Congress. The commission continued to delve into the details of designing a unified post-acute care (PAC) prospective payment system (PPS)
that aims to establish accurate and equitable payments across the PAC sectors. Before this PAC PPS will be implemented, as required by law, in 2021, a three-year transition is necessary in order for refinements to be made to improve the design. One chapter focuses on these refinements, specifically two payment issues relating to sequential stays, and how to identify distinct levels of care for a PAC provider that treats a patient with evolving care needs “in place” rather than referring the patient to another PAC provider for payment purposes. One-third of the 1.9 million multi-stay sequences involve beneficiaries who transitioned from more to less intensive settings, with the most common being SNF and IRF stays. MedPAC reported that using this PAC PPS prototype for institutional stays would remain reasonably well-aligned with the cost of stays throughout a sequence of care, meaning it properly captures differences in the cost of institutional stays throughout a sequence of care, and that there is no need for a separate adjustment to payments. MedPAC notes that one downside of this prototype is that it would not be able to appropriately pay a PAC provider that both offered a range of PAC services and did not refer the beneficiary to another provider. In order for PAC PPS to work in the future, MedPAC states that Medicare must define when one phase of care ends and when the next one begins. MedPAC opined that the most promising approach involves episodebased payments, so Medicare would pay for all PAC provided during an episode of care, excluding other services such as hospital care or physician services. As we go to print, Congress prepares to wrap up a fairly intense period of work and members of Congress will likely be at home more frequently through Labor Day. We urge you to avail yourselves of this opportunity to invite them to visit your hospitals and understand your unique mission and commitment to your patients. We need more educated and committed rehab hospital advocates!
AMRPA Magazine / August 2018
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Recent Developments Impacting DMEPOS
Peter W. Thomas, AMRPA Counsel, and Principal, Powers Law Firm
From time to time, we report on issues that indirectly impact AMRPA members but are critical to Medicare beneficiaries with disabilities and chronic conditions. This article examines two significant developments in the area of access to durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). Access to DMEPOS is largely a concern for individual beneficiaries under their Part B benefits. While specific types of DMEPOS are critical to rehabilitation in an inpatient rehabilitation hospital setting, DMEPOS is fundamental to full function and independent living for people with disabling conditions. First, the Centers for Medicare and Medicaid Services (CMS) recently issued an interim final rule implementing important delays in changes to competitive bidding for DMEPOS. They also issued a proposed rule addressing DME competitive bidding. Second, CMS finally made public the results of its Interagency Workgroup Report on the draft Local Coverage Determination (LCD) for Lower Limb Prosthetics (LLP) issued in July 2015 by the DME Medicare Administrative Contractors (DME MACs). We summarize these developments below. CMS Resumes Use of Transitional 50/50 Blended Rates for DME Fee Schedule In May, CMS issued Interim Final Rule CMS-1687-IFC, allowed for comments to be submitted until July 9, 2018. (Despite the comment period not ending until early July, the changes proposed actually became effective as of June 1, 2018.) The rule adjusts the fee schedule rate to be used in rural and non-contiguous areas (Hawaii, Alaska and U.S. territories) that are outside of the areas covered by the current competitive bidding program (CBP) for DMEPOS. Specifically, the Interim Final Rule resumes use of a “50/50� blended fee schedule rate for items furnished in these areas from June 1, 2018, through December 31, 2018. This is designed to ease the transition from current fee schedule payment amounts to the amounts set under the competitive bidding program. (At the time of publication, CMS also announced a proposed rule that would extend this same level of DME reimbursement in rural areas for another two years, indicating that CMS recognizes that unreasonably low, competitively bid prices have created access problems for Medicare beneficiaries in rural areas across the country.) The Interim Final Rule establishes that, as of June 1, 2018, not all DMEPOS suppliers are subject to the CBP payment amounts. The full phase-in of competitive bidding pricing has raised significant concerns about continued access to quality DMEPOS for beneficiaries, in rural areas particularly. Many feared that the limited number of DMEPOS suppliers serving such beneficiaries may either substitute lower cost (and quality) items or perhaps cease operation in those areas altogether. CMS recognized the negative impact the full fee schedule adjustment has had on beneficiaries in rural and non-contiguous competitive bidding areas and took the proactive step of extending the 50/50 blended rate applicable to the transition period.
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AMRPA Magazine / August 2018
CMS estimates that the extension of the blended rate will cost Medicare beneficiaries approximately $70 million in cost sharing; however, the critical concerns about continued beneficiary access and choice overrode the cost concerns. Furthermore, the true impact of CMS’ cost sharing forecast is unclear due to the widespread existence of secondary insurance. More than 80 percent of traditional Medicare beneficiaries have some type of supplemental coverage, whether it is employer-sponsored, Medigap, or Medicaid.1 The Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition, of which AMRPA is a member, submitted comments to the Interim Final Rule, supporting CMS’ efforts to mitigate the impact of full implementation of nationwide DME reimbursement levels. The ITEM Coalition also recommended that CMS consider further extending use of the blended rate, arguing that the increase in access, quality and choice protected by the transitional rate offset the legitimate concerns of increased beneficiary cost-sharing. The ITEM Coalition explicitly pushed CMS to extend the transition period because: [T]he transition period is not long enough for CMS to be able to meaningfully assess access, choice and quality in rural and non-contiguous CB [competitive bidding] areas. The same negative impacts noted over the past year will apply once CMS reduces fees again in six months’ time, and beneficiaries who receive DME cannot function in their daily lives without this coverage. We urge CMS to consider increasing the length of the transition period until there is data supporting that an end to the transition period reimbursement rates will not decrease access, choice and quality to durable medical equipment for Medicare beneficiaries. As already noted, CMS appears to be on the same page as these concerns, proposing an additional two-year extension in blended DME reimbursement rates in a recently published proposed rule. Interagency Workgroup Issues Consensus Document on Draft LCD on Prosthetics On Wednesday, June 13, 2018, CMS made the Lower Limb Prosthetic Workgroup Consensus Document publicly available online. The consensus document was accompanied by a statement from CMS on actions being taken by CMS as a result of the consensus document. The consensus document was issued in response to widespread public comments and major concerns expressed regarding the DME MAC Proposed/Draft LCD: Lower Limb Prostheses (DL33787, “the Draft LCD”), released July 16, 2015. Coverage, coding and reimbursement changes proposed in that document would have set back amputees to 1970s levels of care. AMRPA participated in this process when the draft LCD was initially proposed and sought major revisions to the policy. At the time, an online White House petition drew support from over 110,000 people, which committed President Obama to respond. The draft LCD was subsequently placed on hold, the interagency workgroup was created, and the report has finally
// While specific types of DMEPOS are critical to rehabilitation in an inpatient rehabilitation hospital setting, DMEPOS is fundamental to full function and independent living for people with disabling conditions. been issued. The workgroup, comprised of federal employees in the lower limb prosthetic field including clinicians, policy specialists and patient advocates from various agencies, was tasked with development of a consensus statement to inform Medicare policy regarding best practices for beneficiary access to lower limb prosthetics. The workgroup also identified areas where evidence gaps exist related to the prescription of lower extremity prostheses. Most importantly, the workgroup recommended that CMS retire the Draft LCD, a recommendation that CMS and its contractors have already confirmed. Across 14 pages, the document identifies the K-level characteristics of individuals classified as K0-K4, describes the process for obtaining a lower limb prosthesis, provides recommendations on prosthetic componentry, highlights research gaps in lower limb prosthetics, and offers several final recommendations for CMS to consider implementing in the short term. The workgroup also issued recommendations regarding coverage of lower limb prostheses generally, including an algorithm for determining proper K levels, use of preauthorization for prescription of lower limb prostheses, certain coverage guidance for specific prosthetic componentry, and steps to advance research in specific areas. Per the statement issued accompanying the release of the Consensus Document, CMS indicates that it is taking the following immediate actions in response to the recommendations of the workgroup: Provide instruction to its DME MACs to remove the Draft LCD. Instead, CMS will defer to the coverage policies under the current LCD, with no changes. CMS further indicates that they will follow LCD processes established in the 21st Century Cures Act (PL 114-255), including a public comment period, if the need for a new or revised LCD arises. Collaborate with the National Center for Medical Rehabilitation Research (NCMRR) of the National Institutes of Health (NIH) to create a guidance document to promote research standards in the field of lower limb prostheses.
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Consider opening an NCD to evaluate the use of microprocessor knees in those individuals utilizing their prostheses as a limited community ambulator, meaning they utilize the prosthesis in the home and to traverse low level community barriers such as curbs, stairs and uneven surfaces. (These activities are consistent with the K2 level of function defined in the current LCD). The retirement of the Draft LCD is a significant win for Medicare beneficiaries and the providers who serve them. The Draft LCD represented a significant threat to access and quality of prosthetic care for Medicare beneficiaries. It will be necessary to see what direction CMS takes with respect to the rest of the workgroup’s recommendations, particularly with respect to prior authorization. Conclusion The most recent steps taken by CMS with respect to DMEPOS generally exhibit a more positive direction and some encouraging signs for continued access, choice, and quality of DMEPOS
items covered for Medicare beneficiaries. For instance, as of the writing of this article, CMS just released proposed updates to policies and payment rates for the DMEPOS competitive bidding program, DMEPOS fee schedule amounts, and the quality incentive program (CMS-1691-P). An initial reading of the proposed rule reveals many positive developments the rehabilitation and disability community has promoted for several years. Inpatient rehabilitation hospitals and units, as well as the rehabilitation professionals who practice within IRFs, will need to remain up-to-speed on these developments given their potential to significantly impact rehabilitation patients’ access to DMEPOS items post-discharge. Written by Peter W. Thomas, Counsel, AMRPA Consumer and Clinical Affairs Committee and Denials Management Task Force, and Christina A. Hughes, Counsel, Powers Pyles Sutter & Verville, PC. 1 An Overview of Medicare, KAISER FAMILY FOUNDATION (Nov. 2017), https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/.
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FIM Essentials for the PPS Coordinator
Lisa Werner, MBA, MS, SLP
Mastering the essentials is necessary for reporting accurate and valid Functional Independence Measure (FIM) scores on the IRF-PAI. Because FIM is currently the basis of our rehabilitation prospective payment system (PPS), attention must be paid to training, education and data collection at admission and discharge. With the electronic medical record, it is common to see scores pulled directly from a FIM flowsheet into your eRehabDataÂŽ patient assessment. Through my experience conducting charge audits for clients and validating the scores against written documentation, I often find that the PPS coordinators are trusting the scores pulled in, rather than validating the data against the written documentation. These discrepancies arise in approximately 40 percent of the records that I review. That is a substantial number, given the weight that the FIM scores have in the case mix group (CMG) capture. The following strategies are designed to help you make sure that documented FIM scores on the IRF-PAI capture the true burden of care. Conduct annual classes. Classes are a good way to make sure that all staff are on the same page regarding their understanding of FIM concepts and individual item scoring. Classes are also an important way to make sure there is consistency in the way you approach FIMs and score each item. When I teach classes, I prefer to have therapists and nurses take the same class together. This addresses multiple concerns: each team member has a tendency to focus on the items that are most commonly associated with their profession, but the overarching concept of burden of care uniformly applies to all items. Sometimes it is easier to understand a concept when it is being applied to an item that you do not normally score and getting a full refresher will be helpful for everyone. And people learn different things from different instructors. Having one instructor teach the entire group assures a uniform procedure. Keep in mind that if someone scored differently in one item, it is best to address differences in the group. Everyone should have an equal opportunity to learn. Test staff every year. I recommend that you do this at a time other than when classes are held. Think spring training, fall testing. Make it open book to reflect that staff should always have resources available to them when they are assessing a patient and documenting the encounter. The tests should be like real life: tricky. Make sure that your questions address situations that are as difficult as real life can be. For example, when a nurse takes a patient to the bathroom, they would likely assess toileting, toilet transfers and bladder. If the tests ask about one item at a time, it would be easier than real life and therefore would not provide much benefit as a training resource. Regarding scoring, results are subjective based on facility standards. If I told you that anything less
AMRPA Magazine / August 2018 11
than 100 percent is acceptable, that would not be fair because the conditions that govern my facility’s circumstances are not identical to yours. For the eRehabData® Proficiency Exams, we do not provide a score. Instead we allow each facility to set the passing standard for their staff. Lastly, it is pivotal to score everything with 100 percent accuracy, keeping in mind that FIM’s are a vital part of our CMG payment. Follow up on test results. Once you finish testing, take the time to go over the test and results with staff members. That might be the best learning experience of all for everyone involved. It is important to review the results so staff understand errors that might have been made, the correct response, and why. Use reports to identify weaknesses in the current procedure. The outcomes reports will tell you where your scores are higher at admission and lower at discharge than those in your region or in the nation. We provide case mix adjusted values as well. That number indicates how you scored patients compared to a similar set of patients in the nation or region. Design training modules for areas that need improvement. These can be quick tips, case scenarios, or three-to-five slide presentations that you could incorporate into monthly staff meetings. The idea is to keep FIMs as agenda items for all of your regular staff meetings. Rather than just thinking about FIM competence once a year, make it a yearround educational process. Emphasize the burden of care. When you train, emphasize that FIM is not a test. It is a measure of the burden of care required to care for a patient. Those two things are very different. They should make us think differently. Of course, we all want to see our patients improve in function, but if we are not realistic about how much is required to take care of them, we may not set an appropriate treatment plan or family training plan to safely and effectively get them home. Be sure staff members understand the importance of documenting the amount of care needed to manage a patient. Encourage your staff to trust their instincts. We should never strive to see uniformity in FIM scores throughout the day. It is reasonable to assume that patients will perform differently around various providers secondary to fatigue, lack of motivation or lack of mastery of the activity. To prove that the patient is progressing, we would naturally want to see nurses get the same results as therapists. I have a hunch, however, that we sometimes put pressure on nurses to report higher scores. Nurses should trust their instincts. If they are properly trained and know the difference between an assessment and completing a task for the patient for their own convenience, then they should be empowered to document the amount of assistance required to care for the patient. If it happens to be a greater amount of care than what a therapist reported, it is not necessarily wrong. We do not expect family members to have a similar level of
12 AMRPA Magazine / August 2018
expertise to therapists, so the input about the patient’s level of function at the end of day and overnight will help us prepare both the patient and caregiver for discharge. The last thing we want is to make staff feel that their scores have to match those of other providers because it risks having them copy someone else’s score rather than trusting their instincts. Make sure that all assessments are recorded when observed. We tend to focus our attention on admission scores and discharge scores, but the scores in the middle are also important. If you are not documenting performance throughout the day, you run the risk of not having any scores in the case of an unexpected discharge. This results in negative FIM gain during the stay. Instruct staff on the difference between an assessment and a non-scorable opportunity such as when a staff member completes a task for the patient for their own convenience. Make sure that they know what to score and are empowered to record all assessments. Review PPS payment and how a FIM score impacts reimbursement. Include a review of our payment system in your annual FIM training. It is important for staff to know how their scoring fits into the big picture of determining a case mix group and payment to the hospital. Spot check charts. Review your score-gathering process and IRF-PAI completion process. Be sure that what is recorded in the chart matches what was reported on the IRF-PAI. Take a look at all of the notes in the first three days and for the discharge scoring window. Scores often come from a FIM scoring report or worksheet, but all of the documentation should be reviewed to ensure the true burden of care is reported on the IRF-PAI. Create case studies. Use the information from your spot checks to review concerns with staff, both one-on-one and with the group. Use examples of missed opportunities to improve documentation, patient assessment and recording scores on the FIM sheets. Additionally, indicate how length of stay and reimbursement would be impacted if corrected scoring yields a different case mix group for the patient. Compile these case studies to use in future staff meetings, training classes or mentoring sessions with new employees. Real examples are the most powerful of all. Following the strategies outlined here will help ensure that FIM scores are correctly captured in your facility. Conducting annual classes, training staff every year, and empowering your staff to trust their instincts and record data correctly will all help result in a greater percentage of CMG accuracy and eliciting the best reimbursement for each case.
A M E R I C A N M E D I C A L R E H A B I L I T AT I O N P R O V I D E R S A S S O C I AT I O N
Improving Access to Inpatient Rehabilitation Hospitals and Units www.AMRPAPAC.org
AMRPA Magazine / August 2018 13
MedPAC Issues Annual June Report; Explores Additional Issues Related to PAC PPS and Promoting Use of High-Quality PAC Providers In mid-June, the Medicare Payment Advisory Commission (MedPAC) released its annual mid-year report: Report to the Congress: Medicare and the Health Care Delivery System. The report covers numerous Medicare issues, however, two chapters are of particular interest to rehabilitation hospitals and units and other post-acute care (PAC) providers: Chapter 4, Paying for Sequential Stays in a Unified Prospective Payment System for PAC and Chapter 5, Encouraging Medicare Beneficiaries to Use Higher Quality PAC Providers. Both chapters are discussed below.
Carolyn C. Zollar, MA, JD, Executive Vice President for Government Relations and Policy Development
Mimi Zhang, Senior Policy and Research Analyst
Use of Sequential Stays As in the past two years, MedPAC discussed its proposal for a unified post-acute care prospective payment system (PAC PPS). As readers will recall, MedPAC was directed by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 to evaluate and recommend features of a PAC PPS based on data from the Post-Acute Care Payment Reform Demonstration (PAC PRD) which was mandated by the Deficit Reduction Act of 2005. Based on its analysis of 8.9 million PAC stays in 2013 and using readily available administrative data, the commission concluded that a unified PPS is feasible. The PAC PPS design would use a stay as the unit of service (which in the case of home health care is defined as an episode) and a uniform risk adjustment method. MedPAC found the following factors to be important predictors of costs: the patient’s age, disability status, comorbidities (and the number of body systems involved), severity of illness, risk score, cognitive status, impairments, the primary reason to treat, the length of stay in an intensive care unit during the prior hospital stay (if any), and the use of select high-cost services (such as dialysis and mechanical ventilation). However, MedPAC’s recommended model does not include functional data, which it felt could be added at a later date. In its June 2017 report, the commission further explored various issues related to the PAC PPS and recommended again, based on the same analysis of 2013 PAC stays (with costs and payments updated to 2017), that the Congress direct the secretary of the Department of Health and Human Services (HHS) to implement a PAC PPS beginning in 2021, with a three-year transition and payments lowered by 5 percent (absent any prior payment reductions made to any setting’s payments). Concurrently, the secretary should begin to align setting-specific regulatory requirements. MedPAC
14 AMRPA Magazine / August 2018
is very eager to see its PAC PPS adopted and implemented. Hence in this year’s March report the commission recommended that Congress direct the HHS to blend PAC provider payments using their setting-specific PPS rates plus MedPAC’s PAC PPS relative weights. In this June report MedPAC explores additional areas related to the implementation of the PAC PPS. Specifically, it addresses sequential PAC stays, how to define them and how to pay for them. Definition of Sequential PAC Stays Although a majority of patients have just one PAC stay after discharge from the hospital, many of them have a series of stays. The commission used beneficiary identifiers and admission and discharge dates to link sequences of PAC stays together to examine these stays. This method allowed it to identify common trajectories of PAC use (e.g., a single IRF stay, a SNF stay followed by a home health stay, back-to-back home health stays). Hence, a sequential PAC stay refers to care furnished to a beneficiary with short or no gaps in between the stays. For MedPAC’s analysis, it defined a sequential stay as one that began within seven days of another PAC use. These rules are rough proxies for clinical relatedness while allowing some flexibility regarding arranging home health care. Changes in institutional PAC setting (IRF, SNF, LTCH) stays typically involve transferring the beneficiary with no days in between the stays. Sequences include stays in the same setting and in different settings. A “first” stay was defined as having no PAC use within the previous seven days. For example, a SNF stay followed by a home health episode that began within seven days of discharge from the SNF was considered a two-stay sequence. MedPAC assigned stays to the following groups based on the dates of the stay: Solo (first-and-only) stays consisted of one admission to one PAC provider, with no subsequent care. First-of-multiple stays were the first in a sequence of PAC stays. Subsequent stays were the second, third, or later in a sequence of PAC. The commission aggregated the three institutional-type stays into a single “institutional PAC” group to reflect how a PAC PPS would pay for this care. The PAC PPS would ignore differences among institutional settings in establishing payments for these providers and would separately adjust HHA (home health agency) payments to recognize the considerably lower HHA costs. In the online appendix 4-A, MedPAC includes a table showing the 25 most frequent sequences of PAC (duplicated below). Apparently solo IRF stays are the seventh most frequent stay. Characteristics of Sequential PAC Stays As background to its analysis of the costs of and payments for sequential stays, the commission first examined the patterns of PAC use in 2013. Of the thousands of multi-stay sequence patterns, the 10 most frequent patterns made up three-quarters of these sequences. Multiple home health stays were the most common. Stay sequences with decreasing intensity were three times as frequent as those with increasing intensity.
// In this June report MedPAC explores additional areas related to the implementation of the PAC PPS. Specifically, it addresses sequential PAC stays, how to define them and how to pay for them. Beneficiaries with solo stays differed from those with multistay sequences. Among home health stays, beneficiaries with multi-stay sequences were more likely to be dually eligible for Medicare and Medicaid, disabled and admitted from the community, while beneficiaries with multiple institutional PAC stays were less likely to have those characteristics. Compared with providers of solo home health stays, providers of multi-stay sequences were more likely to be for-profit and freestanding. In contrast, institutional PAC providers of multi-stay sequences were more likely to be non-profit and hospital based compared with providers of solo institutional PAC stays. Frequency of Sequential PAC Stays MedPAC identified 5,762 combinations of PAC stays in 2013. About two-thirds (64 percent) of the stays were solo events—that is, consisted of a single stay. Of solo stays, home health stays made up the majority (67 percent), while SNF stays made up 28 percent, IRF stays another 4 percent, and LTCH stays about 1 percent. About one-third (36 percent) of the combinations involved multiple stays, with beneficiaries transitioning from one PAC setting or provider to another during their course of care. Pairs of PAC stays were the most common multi-stay sequence. Half of the sequential stays were lateral transitions within the same setting. The most frequent of these lateral, same-setting sequences consisted of home health stays only. Beneficiaries who moved from more intensive PAC care to less intensive care made up one-third of multi-stay sequences. Transitioning from a SNF or an IRF to home health care was the most common combination of stays of decreasing PAC intensity. Far less frequently (10 percent of multi-stay sequences), beneficiaries were discharged from a lower level of PAC to a more intensive setting. Presumably, this trajectory reflects a change in care needs of the beneficiary and capabilities of the provider or caregiver at home. Of those, transitions from a home health stay to a SNF stay were the most frequent. The remaining 7 percent of sequences were a mixed pattern of transitions (of increasing and decreasing intensity over the course of care), the most frequent being transitions back and forth between SNFs and HHAs. Of all multi-stay sequence patterns, the 10 most frequent made up three-quarters of these sequences. Multiple stays in HHAs were the most common: Sequential home health stays made
AMRPA Magazine / August 2018 15
up 42 percent of all multi-stay sequences, with a pair being the most frequent (21 percent of multi-stay sequences). What appears to be continuous home health care during the year (six or more episodes) made up 7 percent of multi-stay sequences. The commission then examined the characteristics of solo and multiple home stays, solo and multiple institutional PAC stays, and of the providers of solo and multi-stay sequences. It noted that the average cost of stays declines throughout a sequence of care, and institutional PAC stays in particular generally declined throughout a sequence, though the pattern was a little more variable and the differences were smaller compared with home health stays. Except for the two-stay sequence, the costs of later stays were between 7 percent and 12 percent lower than first-stay costs. Compared with later stays, first-stay costs were higher in part because they involved a costlier mix of settings. For example, 21 percent of first-of-multiple stays were IRF stays compared with 10 percent of fifth stays. However, MedPAC expressed concern that if risk adjustment does not adequately capture the differences in patient complexity throughout the sequence, later stays will be less profitable, and providers of subsequent stays could be discouraged from admitting these beneficiaries, creating placement problems for beneficiaries with extended PAC needs. Home health agencies also experience greater profits, as a stay commenced their cost declined but payment stayed the same. Institutional PAC providers’ profitability remained relatively the same throughout the entire stay as costs did not decline as noticeably. MedPAC then looked at the concept of treating in place, which is a concept that is part of AMRPA’s Continuing Care Hospital (CCH) framework as well. For institutional PAC providers furnishing a continuum of care, the end of one stay and the beginning of another would be less clear and hence CMS will need a way to distinguish between the different phases of care. Otherwise, with one admission and one discharge, a provider opting to treat in place would receive one payment that may not be sufficient to cover the costs of an extended phase of PAC. Providers that treat in place would then be at a financial disadvantage compared with providers that refer the beneficiary to another level of care. Yet, if treating in place would offer comparable care and reduce the risk of untoward outcomes from a poor transfer, providers opting to treat in place should not be discouraged. MedPAC looked into defining a stay based on time and noted that in so doing there would be an incentive to increase the volume of subsequent stays for payment purposes. Finally, the report concluded another approach that would elude many of the thornier issues would be to shift the unit of service from a “stay” to an episode of care. This design concept was mentioned in its original report on the PAC PPS as a second step once the initial program using stays was implemented. An episode-based payment would require one entity to be financially at risk for the entire episode of care. The entity could be the first PAC provider, a health care system, a hospital, an accountable care organization (ACO), a physician group practice, or a third-party convener. This entity would need to have the infrastructure to receive a lump-sum payment from Medicare and, in turn, make payments to any downstream PAC providers furnishing care during the episode. If the first 16 AMRPA Magazine / August 2018
PAC provider is the entity at risk, it could opt to furnish all PAC for the episode or refer the beneficiary to another PAC provider that it would pay. MedPAC estimated that a minority of episodes (about 18 percent) would involve paying more than one provider, and expected this share to decline substantially under a PAC PPS as providers opt to offer a continuum of PAC. Episode-based payments for providers underscores the need to align Medicare coverage rules and beneficiary cost-sharing requirements across PAC settings, which AMRPA has advocated against. For example, a prior hospital stay of three days is currently required for SNF coverage but not for HHA, IRF or LTCH services. As distinctions between particular institutional settings blur and providers opt to offer a broader mix of services, it would make sense to have one set of coverage rules. Likewise, beneficiary cost-sharing requirements currently vary by setting. Also, standardized cost sharing would enable beneficiaries to select PAC based on their care needs and preferences rather than on financial considerations. MedPAC sees both advantages and disadvantages of episodes of care. First, with respect to advantages, an episode-based payment would overcome the distortions inherent in volume-driven fee-forservice (FFS) payment. Providers would have an incentive to furnish a mix of services to meet a beneficiary’s care needs over the entire PAC episode rather than to furnish more stays. MedPAC also saw three potential downsides to episode-based payments. First, providers would have a financial incentive to furnish fewer services than medically appropriate or provide lower quality care if it lowered their costs. The potential for providers to stint on care is inherent in any prospective payment system. Second, episode-based payments could encourage more episodes, resulting in increased program spending. However, the risk of more episodes would be lower than the risk of unnecessary subsequent stays because the decision to use PAC would be made by the beneficiary’s physician in consultation with discharge planning staff (as it is now), whereas, under the length of stay approach, the decision to generate additional stays would be made by the PAC provider. Finally, an episode-based payment would require the entity at risk to have the infrastructure needed to pay multiple providers. Although episodes that involve multiple providers represent the minority of episodes, some PAC providers would not be ready to accept this level of financial risk or have the administrative infrastructure to set and make payments to other providers. MedPAC plans to explore using an episode-based approach in the coming year. At the same time, it again urged CMS to implement its original stay based PAC PPS. To date, CMS has not responded to MedPAC’s proposal. Use of Higher Quality Post-Acute Care Providers In 2015, about 40 percent of Medicare hospital discharges resulted in use of at least one of the four post-acute care (PAC) settings (IRF, SNF, HHA or LTCH). Selecting the type of PAC setting is a highly important decision guided primarily by the patient’s physicians and care team. Likewise important is the selection of a provider within a PAC type, according to MedPAC, particularly because the quality of care can vary widely
Table 1. The 25 most frequent sequences of post-acute care* (Duplicated from MedPAC’s online appendixes Table 4-A1) Sequence
Frequency
Table 2. Medicare initiatives that place hospitals at financial risk for readmissions from post-acute care
Percent
Cumulative Percent
42.9 %
42.9%
H
2,290,337
S
969,965
18.2
61.1
HH
400,527
7.5
68.6
SH
322,159
6.0
74.7
HHH
144,493
2.7
77.4
SS
125,440
2.4
79.7
I
123,523
2.3
82.0
HHHHHH
112,255
2.1
84.2
IH
97,679
1.8
86.0
HS
95,162
1.8
87.8
HHHH
72,678
1.4
89.1
L
51,367
1.0
90.1
HHHHH
46,424
0.9
91.0
SHH
36,372
0.7
91.6
SSH
27,253
0.5
92.2
IS
23,711
0.4
92.6
SSS
21,014
0.4
93.0
SHS
20,724
0.4
93.4
HSH
19,917
0.4
93.8
LS
18,733
0.4
94.1
HHS
16,322
0.3
94.4
HI
15,218
0.3
94.7
HSS
13,242
0.3
94.9
IHH
12,035
0.2
95.2
ISH
10,860
0.2
95.4
246,966
4.6
All other
Financial incentive to prevent readmissions
Initiative
Participation
Inpatient hospital value-based purchasing (VBP) program
VBP incentive that pays hospitals bonuses or imposes penalties based on their performance
Mandatory for all IPPS hospitals
Hospital Readmissions Reduction Program
Penalty for hospitals that exceed expected rate of readmission for six conditions
Mandatory for all
Comprehensive Care for Joint Replacement (CJR)
PPS hospitals
The program includes a financial penalty for hospitals with higher than expected readmissions.
Bundled Payments for Care Improvement (BPCI)
Creates an incentive that holds hospitals accountable for cost and quality of the inpatient acute care services and 90 days of post-discharge care for joint replacement patients
Mandatory for all hospitals in 67 selected urban areas (CMS intends to reduce to 34 areas in 2018)
Hospitals in CJR can receive a bonus or penalty depending on their aggregate spending in the payment bundle. Lowering readmissions from PAC helps keep spending below target.
Accountable care organizations (Next Generation or Medicare Shared Savings Program)
Includes a model that allows hospitals to select a bundle that includes the inpatient stay plus PAC and all related services up to 90 days after discharge; the beneficiary’s condition must be 1 or more of 48 diagnostic groups
Voluntary
Participants in the BPCI initiative can receive bonus payments if they keep spending below a target based on prior utilization.
Payment determination is in part based on a measure of spending in the 30-day postdischarge period.
Source: MedPAC analysis
Hence, the commission sought to develop policies to encourage beneficiaries’ selection of higher-quality PAC providers; this would very likely result in better health outcomes as well as lower Medicare spending and beneficiary cost sharing. To do so, the commission looked at the variability of PAC quality, and the dynamics influencing PAC selection such as discharge planning practices (and Medicare’s rules governing them) and the utility of the PAC quality information available CMS has made available.
100
Note: H (home health stay), S (skilled nursing facility stay), I (inpatient rehabilitation facility stay), L (long-term care hospital stay). The sequence shows the order and count of the stays. For example, a HH refers to a two-stay sequence and both stays were home health care. The 8.9 million PAC stays in 2013 were provided in 5,334,377 sequences of post-acute care. Source: Analysis of 2013 PAC stays conducted for the commission by the Urban Institute (Wissoker and Garrett 2018). *AMRPA added emphasis in bold text to highlight inpatient rehabilitation hospital/unit stays.
among providers, even with one setting. Beneficiaries served by lower-quality PAC providers may experience unnecessary rehospitalizations, a more difficulty recovery, and adverse short- and long-term health outcomes, such as not regaining their premorbid level of function. Choosing high-quality PAC providers is also important as CMS rolls out more value-based reforms (such as the Hospital Readmissions Reduction Program [HRRP], hospital value-based purchasing [VBP] programs, and accountable care organizations [ACOs]), which hold acute care hospitals and other risk-bearing entities accountable for costs related to some hospital readmissions during the post-acute period. See Table 2 to the right.
Variations in Quality The commission reports that local markets often have multiple providers with significant variation in quality. For instance, many areas have multiple SNFs and HHAs available whereas IRFs and LTCHs tend to be concentrated in urban areas. The quality of providers varies widely within a PAC setting. In 2015, there was almost a two-fold difference in the share of patients discharged from IRFs to SNFs between the worst and best performing IRFs. Among SNFs, the commission similarly saw that potentially avoidable hospital readmission rates more than doubled between the best and worst-performing facilities. The commission also examined referral patterns of Medicare beneficiaries who were sent to SNFs and HHAs. They found that, for many beneficiaries, another nearby provider offered better quality care. For example, more than 94 percent of beneficiaries who used HHA or SNF services had at least one provider within a 15-mile radius that had higher performance on a composite quality indicator (developed by MedPAC) than the provider they selected. About 70 percent of beneficiaries who received HHA services had five or more other HHAs within a 15-mile radius that offered better quality than their original provider, while almost half of SNF users had five or more options with better quality. In this analysis, however, MedPAC focused on supply and did not account for other factors –
AMRPA Magazine / August 2018 17
such as a facility’s distance from a beneficiary’s residence, bed availability or a patient’s special clinical needs (e.g., ventilator dependency) – that can influence where patients ultimately go for post-discharge care.
Table 3 . MedPAC’s illustrative examples of policies for revising hospital discharge planning Option 1: Hospitals have flexibility to write their own standards
Option 2: Medicare sets standards to define high quality PAC providers
Medicare’s Discharge Planning Policies As readers are aware, when it comes to choosing PAC providers, beneficiaries and their caregivers seek advice from trusted sources such their physician and care team, family members or friends. Hospital discharge planners might also be an expected source of information given the nature of their work; however, due to Medicare’s discharge planning rules, discharge planners at acute care hospital often have concerns about patient steering and are hesitant to recommend specific PAC providers, including high-quality ones. In recent years, hospitals have assumed greater financial risk for post-discharge outcomes through the CMS programs mentioned above as well as commercial ACOs or bundling initiatives. Nonetheless, Medicare’s discharge planning rules remained unchanged in its reforms with the exception of CJR in which CMS permits hospitals to recommend specific PAC providers (although beneficiaries retain freedom of choice). Furthermore, MedPAC finds that beneficiary selection of a PAC provider has not been influenced by quality data. Although quality information on PAC providers is publicly available on Medicare’s Compare websites, referral patterns indicate that these efforts have not shifted utilization to high performing providers.
Medicare’s role
Medicare Conditions of Participation require hospitals to define criteria
Medicare designates providers that can be recommended (e.g., must be at least three or four stars, better CAHPS® score).
Use of quality measures
Hospitals select measures, allowing for innovation and experimentation.
Medicare sets hospitals’ selection criteria.
Regulatory safeguards
There would need to be: • Safeguards to prevent financial conflicts of interest • Disclosure of conflict of interest/ ownership/collaboration • CMS approval of individual hospitals’ criteria and monitoring of proper application.
Like the same safeguards stated in Option 1 would be needed, but standards for recommending PAC providers would be clearer.
Beneficiary implications
• B eneficiaries would receive recommendations that reflect quality of PAC care in the market. • It could be confusing to have multiple definitions across hospitals.
• A single set of standards across hospitals would make reasoning behind selected PAC providers more transparent to beneficiaries. • The quality of PAC providers selected would be more consistent.
PAC provider implications
• P roviders would have to consider multiple definitions if working with many hospitals, potentially with different measures for each setting. • Designation as a higher quality provider could vary among hospitals and across geographic markets.
• A single set of standards would result in consistent designation. • There would be consistency across markets as to which providers qualify as higher quality.
Advantages
• F lexibility in the definition of quality would allow hospitals to develop patient-centered definitions and require them to scrutinize referral partners. • Approaches could reflect local PAC markets’ capacity and scope of offerings.
• A single definition of “quality” would provide clear standards for PAC providers, consistent treatment under policy. • The implementation burden on hospitals would be lighter. • Enforcement would be less complex. CMS would need to ensure that hospitals observe sanctioned criteria when recommending PAC providers.
MedPAC suggests reforming discharged planning process to authorize discharge planners to help beneficiaries identify better quality PAC providers. It identifies several policy areas that should be resolved in order to for these changes to be possible. First, a consistent approach to identifying better quality PAC providers would be needed, and quality standards would need to be transparent for PAC providers and beneficiaries. Second, policies would be needed to safeguard against potential conflicts of interest that could ensue from the authority to recommend specific providers. Finally, the criteria to determine what defines a quality provider would need to account for variations in quality across markets since the number of higher-quality providers available in any market will depend on how quality is defined. MedPAC also recommends that beneficiaries should retain freedom of choice, regardless of the approach selected to encourage the use of higher-quality PAC providers.
Disadvantages
• T here would be a greater burden on hospitals to implement and maintain standards, and on CMS to verify and audit standards and their application. • Multiple definitions of higher quality providers could be confusing for beneficiaries and PAC providers.
• I f there were a single standard, the number of designated providers would vary across areas.
The commission developed two main policy options to expand the authority of discharge planners to recommend higherquality PAC providers (see table 3). They include: A prescriptive approach in which CMS sets the specific metrics or standards used to define a higher-quality provider A flexible approach that gives hospitals and discharge planners the flexibility to apply their own standards. There is also a third hybrid approach in which Medicare specifies the certain selection criteria hospitals would need to use while granting hospitals discretion in the application of these criteria. The commission encourages CMS to give thought to issues such as whether a hospital should limit the PAC providers a hospital 18 AMRPA Magazine / August 2018
Source: MedPAC analysis
can recommend to those that meet specific quality levels (e.g., top quarter nationwide or regionally), or give hospitals the authority to indicate the best PAC provider in a local market. In conclusion, the commission sees somewhat of a conflict between Medicare’s current policies, which place a premium on protecting beneficiary choice of PAC provider, but do not encourage beneficiaries to use higher-quality PAC providers. This conflict is especially brought into contrast as more health care providers bear risk for post-discharge patient outcomes. MedPAC recommends reforms that would seek to ease the burden on beneficiaries by giving hospital discharge planners more latitude to offer information about high-quality PAC providers while ensuring that patient preferences are recognized and patient choice is preserved. You can access the complete report, June 2018 Report to the Congress: Medicare and the Health Care Delivery System, on MedPAC’s website at www.medpac.gov.
AMRPA Submits Comments on the FY 2019 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Proposed Rule Editor’s Note: On June 22, 2018, the American Medical Rehabilitation Providers Association (AMRPA) submitted detailed comments to the Centers for Medicare and Medicaid Services (CMS) regarding the FY 2019 IRF PPS proposed rule. Our primary concern was the agency’s proposal to create a new case-mix classification system and new Case Mix Groups (CMGs) for payment purposes in FY 2020 and associated changes to the IRF-PAI. AMRPA urged CMS to refrain from finalizing these proposed changes to the IRF-PAI and to the CMGs.
June 22, 2018
A summary of AMRPA’s recommendations is printed below, and the complete letter is available at www.amrpa.org. AMRPA thanks those member volunteers who contributed their time and effort to help develop our comment letter.
Dear Administrator Verma:
The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services Attention: CMS-1671-P 7500 Security Boulevard Baltimore, MD 21244-1850 Delivered Electronically RE: CMS-1688-P “Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019, Proposed Rule” 83 Fed. Reg. 20972 (May 8, 2018)
This letter is submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) regarding the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Federal Fiscal Year (FY) 2019 Proposed Rule, published in the Federal Register on May 8, 2018. AMRPA is the national trade association representing more than 625 freestanding inpatient rehabilitation hospitals and rehabilitation units of general hospitals (collectively referred to as inpatient rehabilitation facilities (IRFs, hereinafter referred to as IRH/Us) by the Centers for Medicare and Medicaid Services (CMS)), outpatient rehabilitation service providers, long-term care hospitals (LTCHs), and several skilled nursing facilities (SNFs). The vast majority of our members are Medicare participating providers. In 2016, inpatient rehabilitation hospitals and units (IRH/Us) served 350,000 Medicare beneficiaries with more than 391,000 IRH/U stays.1 On average, Medicare Part A payments represent more than 60 percent of IRH/U revenues. Any alterations to the Medicare payment system have substantial implications for these medical providers. IRH/Us provide hospital-level care, which is significantly different in intensity, capacity, and outcomes from care provided in non-hospital post-acute care settings. AMRPA members help their patients maximize their health, functional ability, independence, and participation in society so they are able to return to home, work, or an active retirement.
1 Medicare Payment Advisory Commission, Executive Summary, in REPORT TO THE CONGRESS, MEDICARE PAYMENT POLICY xx. (Mar. 2018)
Our substantive comments are found in the attachments to this letter. These comments reflect extensive feedback from the medical rehabilitation industry, including professionals involved in every aspect of the treatment of IRH/U patients. Over the past two months, AMRPA has convened multiple committees and workgroups with experts from the field to analyze closely and comment on every aspect of the proposed rule. The diverse range of perspectives and robust discussion and debate involved in crafting these comments ensure that these recommendations
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reflect the most knowledgeable and thorough understanding of the proposed rule and its impact on IRH/Us and their patients. Our primary concern is the proposal to create a new case-mix classification system, hence new Case-mix Groups (CMGs) for payment purposes, by utilizing data collected on the inpatient rehabilitation facility patient assessment instrument (IRF-PAI) as proposed to be amended. As we stated to the Secretary and you in our May 18th letter, we oppose moving forward with these proposed changes which would result in a new set of CMGs upon which IRH/Us would be paid starting with Fiscal Year 2020 (FY 2020) at this time. We respectfully urge CMS to refrain from finalizing these proposed changes to the IRF-PAI and to the CMGs for the reasons stated more fully in our attached analyses and comments.
Additionally we appreciate the agency’s desire to reduce the regulatory burden on physicians in proposing several changes to the IRH/U coverage criteria We support the proposals regarding removal of the admission order requirement and allowing the Post-Admission Physician Evaluation to count as one of the required face to face physician visits. However, we have reservations about the other three proposals which are detailed below in the recommendations and in Attachment A. Finally, we have included in Attachment B our comment letter on the FY 2019 Inpatient Prospective Payment System/Long Term Care Hospital (IPPS/LTCH) proposed rule pertaining to a proposal to allow IPPS-excluded hospitals to have IPPS-excluded units and other proposed policies that have consequences for IRH/Us.
Our complete recommendations, comments, and analysis of the IRF PPS rule are included in Attachment A and our recommendations, comments and analysis on the IPPS/LTCH rule are included in Attachment B. A summary of our IRF PPS recommendations follow. Summary of Recommendations I. Proposed Removal of the FIM ™ Instrument and Associated Function Modifiers From the IRF-PAI Beginning with FY 2020 and Proposed Refinements to the Case-Mix Classification System Beginning with FY 2020 A. Proposed Removal of the FIM™ Instrument and Associated Function Modifiers From the IRF-PAI Beginning with FY 2020 AMRPA recommends that CMS retain the use of FIM™ items for purposes of CMG determination until such a time that any replacement items, such as the proposed Quality Indicator (QI) assessment items, are proven to be sufficiently valid for payment purposes under the IRF PPS.
B. Proposed Refinements to the Case-Mix Classification System Beginning with FY 2020 AMRPA urges CMS to withdraw these proposals until
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the accuracy, efficacy, and validity of the QI items, and their impact on patient care, are sufficiently understood. For these reasons, AMRPA recommends that the proposed changes to the IRF PPS case-mix classification system and removal of the FIM™ items be delayed until the following concerns are addressed: 1. There must an adequate volume of data consisting of at least two federal fiscal years. 2. CMS should disregard QI data from FY 2017 for purposes of developing payment policy. The first year of data collection should not be included because the field was just beginning to use and integrate these items into their practice, and represents a learning period when data may be more inconsistent. 3. CMS must validate that the proposed QI items are suitable and appropriate for payment purposes in the IRF PPS. 4. CMS must ensure there is standardization in how IRH/Us clinicians are scoring and assessing the QI items. CMS should conduct interrater reliability studies to validate practice consistency in the field. 5. CMS must be much more transparent with this work than it has been thus far. Specifically, the agency should share with stakeholders all background data such as full regression results, the Classification and Regression Tree (CART) analysis, rules used in developing the CART nodes, etc. 6. As part of this effort, CMS must involve stakeholders to a far greater extent and convene at least one technical expert panel (TEP) with members of medical rehabilitation researchers, policy experts, and IRH/U clinicians and coders. With their advisement, CMS should ensure that new processes for patient classification and payment are administratively feasible and straightforward. 7. Any modifications to the IRF PPS should be an improvement over the current payment system particularly with respect to accounting for the burden of care, sensitivity of data elements, and costs of care.
C. Proposed Changes to the Functional Status Score Beginning with FY 2020 1. AMRPA does not support using the proposed QI motor items without additional information. Therefore, we also request the data and analyses which justify that these items are the most suitable ones for predicting cost and are an improvement over the current assessment items. 2. AMRPA requests that CMS explain how patients who are wheelchair-dependent at admission would be accounted for in the new CMGs as the proposed motor function score does not include a wheelchair locomotion item. 3. AMRPA requests that CMS reconcile and clarify the seemingly contradictory statements regarding
the inclusion of cognitive function in the FY 2020 CMGs, and provide further detail regarding how cognitive function would play a role in CMG determination. 4. AMRPA does not support using the BIMS or IRF-PAI Section B items BB0700 and BB0800 to replace the five FIM™ cognitive items. We further recommend that CMS investigate whether there are floor or ceiling effects with the proposed cognitive function items. 5. AMRPA recommends that CMS conduct further study into the relationship between cognitive function and resource use in IRH/Us.
admission order requirement from the IRH/U conditions of payment, especially if this change will reduce unnecessary claim denials, and recommends CMS finalize this proposal. D. Solicitation of Comments Regarding Additional Changes to the Physician Supervision Requirement AMRPA recommends CMS not pursue the concept of remote patient visits as it would provide limited ability for physicians to provide needed hands-on assessments and treatments and reduce the quality of visits, and ultimately overall care, provided in an IRH/U.
E. Solicitation of Comments Regarding Changes to the Use of Non-Physician Practitioners in Meeting the Requirement Under § 412.622. (a (3), (4) and (5) AMRPA recommends CMS not permit Non-Physician Practitioners to perform any of the currently required roles of a rehabilitation physician, including those functions involving the Pre-Admission screening, PostAdmission Physician Evaluation, the Individualized Overall Plan of Care or the Interdisciplinary Team Meetings.
D. Proposed Updated to the Score Reassignment Methodology Beginning with FY 2020 AMRPA does not support the proposals to recode the QI items for self-care, mobility, bowel continence, and bladder continence.
E. Proposed Refinements to the CMGs Beginning with FY 2020 1. AMRPA does not support adopting the FY 2020 CMGs, relative weights, and average length of stay values described in Table 9 of the proposed rule. 2. AMRPA requests that CMS provide the underlying analyses and data so that providers can validate the impact the budget neutral proposal would have on them. 3. AMRPA does not support the proposal to combine certain CMGs in Rehabilitation Impairment Category (RIC) 16 and RIC 17. II. Proposed Revisions to Certain IRF Coverage Requirements Beginning with FY 2019 A. Proposed Changes to the Physician Supervision Requirement Beginning with FY 2019 AMRPA supports the proposal to permit the PostAdmission Physician Evaluation to count as one of the three face-to-face visits during the first week of an IRH/U admission and recommends CMS implement this change.
B. Proposed Changes to the Interdisciplinary Team Meeting Requirement Beginning with FY 2019 AMRPA recommends CMS not finalize its proposal to permit remote physician attendance at team meetings. AMRPA encourages CMS to instead continue to work with physicians and providers to find more meaningful ways to alleviate physician burden while not compromising the physician-driven care that is the hallmark of rehabilitation hospitals and units.
C. Proposed Changes to the Admission Order Documentation Requirement Beginning with FY 2019 AMRPA supports CMS’ proposal to remove the
III. Proposed Revisions and Updates to the IRF Quality Reporting Program (QRP) A. Method for Applying the Reduction to the FY 2019 IRF Increase Factor for Providers that Fail to Meet the Quality Reporting Requirements AMRPA urges CMS to provide more flexibility in its application of the two-percent noncompliance penalty to allow providers an opportunity to correct any errors when a good faith effort to submit data is undertaken, and reserve such harsh penalties for egregious offenders who are flouting their responsibilities under the IRF QRP.
B. Proposed New Removal Factor for Previously Adopted IRF QRP Measures 1. AMRPA supports adopting Factor 8 as a factor for CMS to consider when it evaluates measures for removal from the IRF QRP measure set. We additionally recommend that CMS act to remove the following measures from the IRF QRP, which we believe also meet Factor 8’s criteria for removal: • NHSN Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138); • NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717); and • Influenza Vaccination among Healthcare Personnel (NQF #0431), which is also submitted via CDC/NHSN.
C. Proposed Removal of Two IRF QRP Measures 1. AMRPA supports CMS’ proposal to remove NHSN
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Facility-wide Inpatient Hospital-onset Methicillinresistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716) and Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) from the IRF QRP. 2. AMRPA respectfully requests CMS issue guidance to clarify that the presence of dashes on IRFPAI items O0250A, O0250B, and O0250C is appropriate beginning FY 2019 and will not cause a noncompliance determination.
D. Proposed Policies Regarding Public Display of Measure Data for the IRF QRP While AMRPA supports the public display of the four functional status outcome measures, we have several recommendations to improve how CMS implements this proposal: a. CMS should apply the measures to a uniform Medicare patient population across post-acute care settings that is inclusive of Medicare Part A and Part C beneficiaries. Short of this, CMS should use a uniform patient population that is the lowest common denominator, which would be Part A beneficiaries, for purposes of cross-setting comparisons and for public reporting. b. To help minimize consumer misinformation, CMS should revise the measure names on IRF Compare and Nursing Home Compare to better differentiate the measures, and also display information explaining how the measures are actually different among PAC settings. c. CMS should educate providers well in advance of when these measures will be publicly displayed to explain how performance on the functional outcomes measures are calculated and how the data will be reported to the public. d. CMS should be more transparent with regard to the statistical methodologies and national data it uses to calculate provider performance and make this information available to stakeholders. e. CMS should provide IRH/Us with actionable patient-level data for these measures, and the quality data displayed on IRF Compare should be stratified by clinical conditions.
E. Proposed Changes to Reconsideration Notification Requirements under the IRF QRP 1. AMRPA does not support involving MACs with IRF QRP compliance issues. We recommend that CMS use Cormac as the Medicare contractor for IRF QRP noncompliance outreach and communications. 2. AMRPA recommends that CMS must use at least two methods to notify providers of their noncompliance: QIES-ASAP, USPS, or Cormac. 3. AMRPA supports CMS’ proposal to notify providers of final reconsideration decisions using the same notification processes.
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IV. Proposed Update to the Case-Mix Group (CMG) Relative Weights and Average Length of Stay (ALOS) Values for FY 2019 AMRPA urges CMS to provide the underlying analyses and report the agency uses to update the CMG relative weights and ALOS. V. Facility-Level Adjustment Factors AMRPA urges CMS to include more detailed information in the final rule explaining the agency’s rationale for continuing the freeze of facility level adjustments. We continue to recommend a minimum interval for any change in IRH/Us’ provider-level adjustment factors of once every three years. VI. Proposed FY 2019 IRF PPS Payment Update A. Proposed FY 2019 Market Basket Update and Productivity Adjustment 1. AMRPA respectfully requests CMS provide access to the analyses done by contractors to calculate the market basket update each year. 2. AMRPA recommends that CMS carefully monitor the impact productivity adjustments have on the IRH/U sector, provide feedback to Congress as appropriate, and utilize any authority the agency has to reduce the productivity adjustment. B. Proposed Wage Adjustment for FY 2019 As stated in our comment letter in previous years, AMRPA recommends that CMS utilize the most current wage data (which is already used for acute care hospitals and other PAC providers) to determine the IRH/U wage index to level the recruitment playing field across all post-acute sites of care.
VII. Proposed Update to Payments for High-Cost Outliers Under the IRF PPS for FY 2019 AMRPA supports the policy of setting outlier payments at 3 percent of total estimated aggregate payments. AMRPA continues to request that CMS take all necessary actions to ensure that the full 3 percent of outlier payments are paid out each fiscal year. VIII. Request for Information on Promoting Interoperability and Electronic Healthcare Information Exchange Through Possible Revisions to the CMS Patient Health and Safety Requirements for Hospitals and Other Medicare- and Medicaid-Participating Providers and Suppliers AMRPA recommends that CMS take several interim steps prior to pursuing a change to the Medicare Conditions of Participation (CoPs). These steps include providing incentives for IRH/Us to adopt the use of certified EHR technology, addressing the issue of patient matching, and pursuing ways to encourage EHR vendors to halt information blocking practices. While AMRPA appreciates CMS’ continued efforts to promote appropriate sharing of electronic health information between providers, we
are concerned that CMS is suggesting an amendment to the CoPs pertaining to interoperability in the near future when so much work is still necessary to ensure post-acute care hospitals like IRH/Us have the proper infrastructure to participate in such information sharing. Conclusion AMRPA is committed to working with CMS to strengthen and improve its proposed changes to the IRF PPS case-mix classification system and corresponding changes to the IRFPAI. We are confident our members will collaborate and cooperate with CMS in moving forward to test and demonstrate potential approaches. We share the agency’s goal of reducing administrative burden, but not at the expense of safety and quality improvement efforts or payment system accuracy, and certainly we are unwilling to take risks to embrace a system that may negatively impact access to quality care for the most medically complex Medicare beneficiaries. Accordingly, AMRPA urges CMS to refrain from finalizing the proposal in its current form and under its proposed timeline. AMRPA also shares CMS’ desire to reduce the regulatory burden on providers as proposed with respect to the coverage requirements, as well as in several other areas which we suggest in Attachment A. Finally, we further seek to eliminate provider regulatory burdens and level the playing field for all IPPS-excluded providers as the post-acute care continuum moves toward a more integrated model of service delivery and payment reform.
Cc: Laurence Wilson Jeanette Kranacs Todd Smith Susanne Seagrave Gwendolyn Johnson Mary Pratt Stacey Mandl Tara McMullen Christine Grose Charles Padgett Attachment A American Medical Rehabilitation Providers Association’s Analysis, Comments, and Recommendations on the Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019, Proposed Rule; 83 Fed. Reg. 20972 (May 8, 2018) Attachment B American Medical Rehabilitation Providers Association’s Analysis, Comments and Recommendations on the Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2019 Rates; 83 Fed. Reg. 20164 (May 7, 2018) The full letter including Attachments A and B are available at www.amrpa.org.
AMRPA welcomes continued opportunities to collaborate with the Department of Health and Human Services (HHS) and CMS to refine and improve the IRF PPS. If you have any questions about AMRPA’s recommendations, please contact us or AMRPA’s Executive Vice President for Government Relations and Policy Development, Carolyn Zollar, M.A., J.D., (czollar@amrpa.org / 202-860-1003). Sincerely,
Richard Kathrins, Ph.D. Chair, AMRPA Board of Directors President and CEO Bacharach Institute for Rehabilitation
Mark J. Tarr Chair, AMRPA Regulatory and Legislative Policy Committee President and Chief Executive Officer, Encompass Health
AMRPA Magazine / August 2018 23
AMRPA Submits Letter to CMS Responding to IPPS and LTCH Proposed Rule for Fiscal Year 2019
Jonathan M. Gold, JD, AMRPA Regulatory and Government Relations Counsel
Highlights: »»
AMRPA urges CMS to withdraw proposal to allow long-term care hospitals to operate inpatient rehabilitation units.
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AMRPA also provides comments on wage index and price transparency policies.
On June 22, AMRPA submitted a letter in response to the Centers for Medicare and Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) and Long-term Care Hospital Prospective Payment System (LTCH PPS) proposed rule for fiscal year 2019. There were four areas AMRPA responded to in its letter, including the current disparities in CMS’ wage index policies, CMS proposal to allow IPPS-excluded hospitals to operate IPPS-excluded units, CMS’ policy on the documentation needed for Medicare cost reports, and comments in response to CMS’ request for information on hospital price transparency. Below is a summary of the proposals and AMRPA’s recommendations in the letter. If you would like to read the entire letter, visit the AMRPA website and you can find the letter under the “Advocacy” tab. Request for Public Comments on Wage Index Disparities In the proposed rule, CMS invited public comments, suggestions and recommendations to improve the Medicare wage index through regulatory and policy changes. In response, AMRPA reiterated several concerns it has previously voiced about CMS’ current wage index policy and how it disadvantages inpatient rehabilitation hospitals and units (IRH/Us). First, AMRPA pointed out that the current wage policies allow acute care hospitals to regularly obtain geographic reclassifications and other adjustments that are not afforded to post-acute care (PAC) providers such as IRH/Us, despite these PAC providers needing to compete for clinical staff in the same markets as acute care hospitals. Second, AMRPA reminded CMS that the wage index utilized for IRH/Us is the prior year, prereclassified acute care hospital wage index, despite other PAC providers (e.g., LTCH, skilled nursing facilities and home health agencies) having their payment system updated using the current fiscal year IPPS pre-reclassified acute care hospital wage index. AMRPA concluded that these policies, especially in sum, disadvantage IRH/Us’ ability to recruit and retain clinicians, with no sound policy reasoning for the discrepancy. AMRPA recommended that CMS take steps to bring equity to the wage policies between all facilities so that rehabilitation hospitals and units can continue to provide high-level clinical services in their hospitals. Proposed Changes to Regulations Governing Excluded Units of Hospitals Currently, IPPS-excluded units, such as inpatient rehabilitation or psychiatric units, can only be located in acute care (IPPS) hospitals. CMS proposes to change this to allow an IPPS-excluded hospital to operate an IPPS-excluded unit in an
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attempt to reduce regulatory burden and achieve program simplification. However, this would also mean that an LTCH would be permitted to operate an inpatient rehabilitation unit (IRU), while an inpatient rehabilitation hospital (IRH) would not be able to host LTCH beds within their hospital because LTCH units are not permitted by statute. AMRPA responded by opposing this proposed change because it would create inequitable standing among PAC hospitals, and would have unintended consequences on competition, patient access, and ultimately the Medicare program as a whole.
to put patients over paperwork. AMRPA pointed out that for some systems that operate multiple locations, this requirement means that they need to submit the same HOCS dozens, or even hundreds of times. This duplicative submission would be burdensome for both providers and the Medicare Administrative Contractors (MACs) alike. AMRPA recommended CMS simplify this requirement by allowing access to HOCS for all MACs via an electronic system so that one submission would be available for review and processing by all contractors for all sites.
The first concern that AMRPA articulated in the letter is that this proposal would significantly disrupt the current delivery of PAC services with little to no analysis of the potential effects, consideration of relevant factors, input from stakeholders or congressional instruction. AMRPA stated that any change of this magnitude should involve extensive stakeholder outreach and analysis to determine the best way to move forward with consolidating any sites of care. Second, AMRPA expressed concern that this proposal essentially picks winners and losers among sites of PAC by allowing LTCHs to operate IRUs, but not vice versa, and that disadvantaging IRHs in this manner would only negatively impact patients. AMRPA argued that rehabilitation hospitals have been at the cutting-edge of innovation and delivery of care for patients in need of intensive rehabilitation services for decades, and that forcing IRHs to compete with LTCHs, which would have the advantage of being able to consolidate sites of care in a manner not being afforded to IRHs, would only hamper rehabilitation hospitals’ future efforts to be leaders in delivering the highestquality care to patients.
Requirements for Hospitals to Make Public a List of Their Standard Charges Via the Internet CMS proposes to update its guidelines to require hospitals to make available a list of their current standard charges via the internet in a machine readable format and to update this information at least annually. In response, AMRPA advised CMS to reconsider any further changes to the requirement to post standard charges for items and services for Part A services. AMRPA pointed out to CMS that standard charges for Part A services, such as the Diagnosis Related Group (DRG) or Case Mix Group (CMG) payment rates (or the equivalent for other payors), are almost never useful to consumers, and in the few cases when they are, it is for noninsured individuals, and not Medicare beneficiaries.
AMRPA also argued in the letter that alternatives currently available for IRHs to operate LTCHs, namely a hospital-withinhospital (HwH) arrangement, is a regulatory complex and burdensome undertaking that is not on par with the flexibility that LTCHs would have under this proposal to integrate an IRU as a unit of their hospitals. AMRPA made several suggestions regarding changes CMS could investigate making to the HwH regulations as well as its current interpretations of the Medicare Conditions of Participation (CoPs) to provide parity to all PAC hospitals. Ultimately, however, AMRPA recommended CMS completely withdraw its proposal and conduct stakeholder outreach and other due diligence before moving forward with any proposals that would begin integrating PAC sites of care. Proposed Revisions of the Supporting Documentation Required for Submission of an Acceptable Medicare Cost Report CMS proposes to amend regulations to specify that for providers claiming costs on their cost report that are allocated from a home office or chain organization, a cost report will be rejected for lack of supporting documentation if it does not include a Home Office Cost Statement (HOCS) completed by the home office or chain organization. While AMRPA supported CMS’ efforts to ensure every chain organization submits a HOCS, it believes this policy would be overly burdensome and runs contrary to CMS’ efforts
In addition to the specific proposed change, CMS also issued a request for information (RFI) seeking feedback from providers on what other changes it could implement to enhance price transparency for consumers, including whether CMS should require disclosure of standard prices or costs for consumers before providing services, as well as how CMS should go about enforcing any price transparency requirements. Generally, AMRPA urged CMS to rethink its approach to price transparency, especially as it pertains to Medicare beneficiaries and Part A services. Since under current policies Medicare beneficiaries have dynamic out-ofpocket payment obligations that fluctuate as the beneficiary reaches their deductible or spends a certain amount of time in a hospital, it would be difficult for hospitals to know exactly how much the beneficiaries out of pocket obligation will be. However, Medicare, which tracks beneficiary utilization across providers, is in a much better position provide that information to consumers, rather than hospitals who may just be one of many providers for that beneficiary. Additionally, patient diagnosis and treatment needs often fluctuate, and it may lead to confusion and delay in needed services for hospitals to be required to continually update patients as to the costs being incurred, especially if that information is not usually relevant to the patient’s personal financial obligations for those services.
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Recent Updates to HHS Inspector General Work Plan
The Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services has a dynamic work plan that is periodically updated with new investigations being performed by the OIG. Here are the highlights some of these investigations and expected reports by the OIG that may be of interest to AMRPA members:
Jonathan M. Gold, JD, AMRPA Regulatory and Government Relations Counsel
Inpatient Rehabilitation Facility Payment System Requirements: The OIG says this review was initiated in 2016 and a report is expected in 2018. The office says prior reviews of individual inpatient rehabilitation facilities (IRFs) have identified substantial Medicare overpayments, and that it will review IRF claims to determine nationwide compliance with the IRF condition of payment regulations. (OIG Report #W-00-15-35730; Release Expected 2018). Denials and Appeals in Medicare Part C: The OIG says due to the financial incentive to deny service inherent in the capitated payment models for managed care plans, it will examine national trends and CMS’ oversight Medicare Advantage (Part C) plans for claims between 2014 and 2016. The OIG says that in addition to evaluating CMS's efforts to monitor and address inappropriate denials in Part C, it will also determine the extent to which denials appealed to each level of review were overturned and variations in appeals and overturned denials across Part C contracts. (OIG Report # OEI-09-16-00410; Expected Release in 2018). Inappropriate Denial of Services and Payment in Medicare Advantage: This report will also focus on oversight of Medicare Part C plans, but as part of this report the OIG states it will conduct reviews of individual medical records in order to determine the extent to which beneficiaries and providers were denied preauthorization or payment for medically necessary services covered by Medicare. (OIG Report #OEI-09-18-00260; Expected Release 2020). Skilled Nursing Facility Prospective Payment System Requirements: The OIG says in October 2017 it began a report examining compliance with the requirement that a Medicare beneficiary be admitted to a hospital for at least three consecutive days be eligible for skilled nursing facility (SNF) services (also known as the “three-day rule”). The OIG says prior reviews found many claims were not in compliance with this requirement. (OIG Report #W-00-16-30014; Expected Release 2018). Home Health Compliance with Medicare Requirements: The OIG says it will review claims to examine compliance with various aspects of the home health prospective payment system regulations, such as whether beneficiaries are properly homebound or in need of skilled services. This report will include a medical review of the documentation required in support of the claims paid by
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Medicare. The OIG says CMS’ Comprehensive Error Rate Testing (CERT) program determined that the 2014 improper payment rate for home health claims was 51.4 percent, or about $9.4 billion in improper payments, and that the OIG has found similar high error rates in its own review of home health claims. (OIG Report #W-00-16-35712, W-00-16-35501 & W-00-17-35712; Expected Release 2018). Review of CMS's Action on CERT Data: According to the OIG, it previously recommended that CMS utilize the Comprehensive Error Rate Testing (CERT) program to target specific error prone providers in order to reduce improper payments. The office says it will examine whether CMS has made any of the recommended changes in the CERT program and also analyze CERT data to identify errors and potential patterns where further interventions could reduce payment errors. (OIG Report # W-00-16-35788; Expected Release 2018). Review of Statistical Methods Within the Medicare Fee-For-Service Administrative Appeal Process: The OIG says it is undertaking a review of whether the Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) are properly reviewing the use of statistical sampling to identify and recover improper payments from providers. Statistical samples used to
recover payments from a provider are appealable, and if the sample is overturned during the appeals process then the provider is liable only for any overpayment upheld in the sample rather than the full, extrapolated total. The difference between these amounts is often substantial, so the OIG says it is vital the MACs and QICs who handle the first two stages of appeals for Medicare providers properly review these statistical samples. (OIG Report # W-00-1835806; Expected Release 2019). Questionable Billing for Off-the-Shelf Orthotic Devices: The OIG says that claims for three off-the-shelf orthotic devices, two of which are lumbar orthotics and one that is a knee orthotic, increased by 97 percent from 2014 to 2016. In reviewing claims for these orthotics the OIG says it will examine whether beneficiaries are being supplied these orthotic devices without an encounter with the referring physician and will also analyze billing trends on a nationwide scale. (OIG Report #OEI-07-17-00390; Expected Release 2019). You can find OIG reports and check for updated work plans at the HHS OIG website at https://oig.hhs.gov under the “Reports and Publications” tab.
Let’s Stay in Touch
AMRPA has new phone and fax numbers. Please see the changes below to update your records. AMRPA Government Relations & Policy Team AMRPA Main Phone: 202-591-2469 Fax: 202-591-2445
Mimi Zhang, AMRPA Senior Policy and Research Analyst Direct Phone Line: 202-860-1003
Carolyn Zollar, JD, MA, AMRPA EVP for Government Relations and Policy Development Direct Phone Line: 202-860-1002
Lovelyn Robinson, AMRPA Editorial and Research Assistant Direct Phone Line: 202-860-1005
Jonathan Gold, JD, AMRPA Regulatory and Government Relations Counsel Direct Phone Line: 202-860-1004
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Catherine Beal, AMRPA Staff Associate Direct Phone Line: 202-860-1006
AMRPA Submits Comments to HHS on Ways to Increase Innovation and Investment in the Healthcare Sector Editor’s Note: On July 6, 2018, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Department of Health and Human Services (HHS) in response to its Request for Information (RFI) regarding a workgroup to facilitate dialogue between HHS and those focused on innovating and investing in the health care industry. The complete letter is provided below.
July 6, 2018 The Honorable Alex Azar Secretary U.S. Department of Health and Human Services 200 Independence Avenue, SW Washington, D.C. 20201 The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services 200 Independence Avenue, SW Washington, D.C. 20201 Re: Request for Information (RFI) on the Facilitation of Public-Private Dialogue to Increase Innovation and Investment in the Healthcare Sector Dear Secretary Azar and Administrator Verma: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we write in response to the Department of Health and Human Services’ (HHS) Request for Information (RFI) seeking feedback regarding a workgroup to facilitate dialogue between HHS and those focused on innovating and investing in the health care industry. AMRPA is the national voluntary trade association representing more than 625 freestanding rehabilitation hospitals and rehabilitation units of general hospitals (IRH/Us, or collectively referred to by Medicare as inpatient rehabilitation facilities (IRFs)), outpatient rehabilitation service providers, long-term care hospitals (LTCHs), and several skilled nursing facilities (SNFs). IRH/Us provide hospital-level care, which is significantly different in intensity, capacity, and outcomes from post-acute care provided in non-hospital settings. AMRPA members help patients maximize their health, functional ability, independence, and participation in society so they are able to return to home, work, or an active retirement. The majority of our members are Medicare participating providers and in 2016, IRH/Us served 350,000 Medicare beneficiaries with more than 391,000 stays.1 AMRPA appreciates the Department’s solicitation of comments and we believe that proactive stakeholder engagement of this nature will pay dividends in developing truly innovative solutions to tackle the complicated challenges facing the health care industry. Our comments offer recommendations regarding the composition of the innovation workgroup and recommendations for optimizing the delivery of post-acute and medical rehabilitation care. I. Need for Medical Rehabilitation and Post-Acute Care Representation Across all payers, approximately one in five patients are discharged to post-acute care (PAC) following an acute care hospitalization,2 and 43 percent of Medicare beneficiaries are discharged to PAC.3 PAC is a critically important part of the care continuum and any federal workgroup tasked with discussing health care innovation would be incomplete and misguided without substantive representation
1 Medicare Payment Advisory Commission, Executive Summary, in Report to the Congress: Medicare Payment Policy xx (Mar. 2018) 2 Tian, W. An All-Payer View of Hospital Discharge to Postacute Care, 2013. Healthcare Cost and Utilization Project 1-17 (May 2016). 3 Medicare Payment Advisory Commission. A Data Book: Health Care Spending and the Medicare Program 76 (June 2017).
AMRPA Magazine / August 2018 29
from PAC stakeholders. The rate of private sector innovation and investment in PAC has grown in recent years as both payers and providers increasingly recognize the critical role of post-discharge care in successful patient outcomes. Creating high-value PAC networks is a key priority for many stakeholders today as they prepare for innovative payment and care delivery reforms, such as value-based payments and population health management. It would behoove HHS to recognize where industry players are investing their resources and the Department could follow suit by ensuring that there is adequate PAC representation on its innovation workgroup. The IRH/U sector has long been at the forefront of innovating and improving PAC delivery. Among the sites of care in the PAC continuum, which include LTCHs, SNFs, and home health agencies (HHAs), IRH/Us have the unique distinction of being the site of care that delivers both intensive rehabilitation services and hospital-level medical care.4 In addition, IRH/Us provide care through a unique interdisciplinary team approach, which includes physical therapists, occupational therapists, speech-language pathologists, rehabilitation nurses, rehabilitation physicians, and other clinicians who work in a highly coordinated manner in order for a patient with a serious debility to regain function and quality of life.5 Being the lone site of hospital-level care proficient at intensive therapy delivery for highly complex patients, IRH/Us have led the PAC industry in innovative approaches to recovery from complex injuries and conditions. We strongly urge HHS to include IRH/U representatives on the workgroup. AMRPA would be pleased to serve as the representative for IRH/Us and other medical rehabilitation services. Due to Medicare’s setting-specific and idiosyncratic PAC regulations, AMRPA recommends that HHS also seek representatives from other PAC settings. Representatives with experience specific to their care setting would be able to offer optimal relevant insights regarding perceived barriers to innovation in the industry and how the Department’s programs or regulatory requirements affect them. II. Increasing Transparency between CMS and IRH/U Stakeholders The RFI also seeks comment more broadly on opportunities for increased engagement and dialogue between HHS and stakeholders, including alternatives to the workgroup structure discussed in the RFI. AMRPA has previously recommended that the Centers for Medicare and Medicaid Services (CMS) develop a Post-Acute Care Advisory Council. This council would be dedicated to post-acute rehabilitation care, should be formed within CMS, and given a broad mandate to provide recommendations and ongoing advice to the Secretary and to the Congress on issues relating to Medicare coverage for post-acute rehabilitation services. The Advisory Council would have authority to review and comment on any CMS regulatory changes or activities impacting post-acute care providers,
including: all rulemakings that impact medical rehabilitation providers and patient access to medical rehabilitation care; criteria for documenting medical necessity for post-acute admissions; and the proper use of available research funds and authorities focused on medical rehabilitation, among other topics. G iven CMS’ and other policy makers’ interest in improving the disparate payment systems for different PAC sites of care, the Agency would benefit tremendously from a standing body with relevant expertise. In response to previous RFIs, AMRPA has also called on CMS to establish periodic Open Door Forum (ODF) conference calls with inpatient hospital rehabilitation providers as a way to provide important updates on relevant CMS activities and to solicit stakeholder feedback. We believe that regular ODF calls—such as those that exist for other Medicare providers, including other PAC providers—would facilitate greater transparency and alignment in medical rehabilitation policy. III. Recommendations for Innovating Post-Acute Payment and Care Delivery A. Continuing Care Hospital (CCH) AMRPA knows of no more promising way to revolutionize post-acute payment and care delivery than through testing and adoption of the Continuing Care Hospital (CCH) model. Congress statutorily directed the Center for Medicare and Medicaid Innovation (Innovation Center) to test the CCH model,6 but the prior Administration declined to move forward to test and implement this Congressionally directed model. The model is not only a compelling alternative payment model (APM) but a promising care delivery system reform that would foster better, more coordinated, patient-centric care and disincentivize costly, disruptive and needless transfers. The CCH should be implemented, as it would create important efficiencies, reduce administrative costs, and ultimately improve patient outcomes. The CCH model provides an opportunity to develop a patient-centered care model in which the “silos” established by the various site-specific PAC Medicare payment systems are eliminated. Care under the CCH model is delivered based on individual patient needs and characteristics rather than by conforming to the regulatory requirements of a particular setting. Specifically, the CCH model would organize care around the patient instead of the setting by consolidating different levels of post-acute rehabilitative care into a single enterprise with a single payment system and single method for measuring quality. The CCH could either be real (all care levels in a common physical space) or virtual (all levels operated as a single entity, but in two or more physically distinct locations). In either instance, the payment ramifications and corresponding bureaucratic processes, documentation
4 See 42 C.F.R. § 412.622 (CMS Regulations Require IRH/Us to deliver at least 3 hours of therapy per day, in addition to providing close physician supervision of all patients and treatments, a feature unique among all sites of care). 5 See Medicare Benefit Policy Manual § 110.2.5 - Interdisciplinary Team Approach to the Delivery of Care. 6 42 U.S.C. § 1395cc-4(g).
30 AMRPA Magazine / August 2018
requirements, and placement imbroglios of moving patients among PAC settings are circumvented, allowing clinicians to let these decisions to be driven by patients’ clinical indicators. In addition to the patient-centric orientation of care, the CCH has real potential to realize cost savings due to efficiencies and reduced administrative burden. Payments would be more reflective of actual cost and resource use, and would not include the considerable costs associated with transferring patients among PAC settings or with meeting the extensive and often redundant regulations of the current PAC payment systems. CMS does not require any additional authorizing legislation or appropriations to launch the CCH model. Congress has also given CMS explicit authority to test the CCH model within the context of Innovation Center.7 Accordingly, CMS should expeditiously test the CCH model as an important step in evaluating innovative PAC payment reforms. B. The Continuing Care Network In the absence of administrative action to test the CCH model or other promising PAC delivery system reforms, AMRPA is in the early stages of working with commercial payers to explore opportunities to streamline the delivery of PAC services in the private sector. AMRPA is leading a collaborative initiative to develop and test an integrated post-acute network, known as the Continuing Care Network (CCNet). The objective of the CCNet is to coordinate care across the PAC continuum and ensure patients are treated in the right setting at the right time. Notably, the IRH/U community is pioneering novel delivery and payment models for managed care and engaging private partners to test and ultimately adopt these approaches. Like the CCH, the goal of the CCNet model is to break down the current PAC regulatory silos and create a full-spectrum continuing care collaborative that encompasses post-acute and continuing care with a patient-focused approach and novel incentives for improved outcomes. This approach aligns with the broader evolution in health care: moving toward unified payments that assess value based on both quality outcomes and total costs of care.
We are confident that the model presents an opportunity to integrate continuing care providers through partnerships with one another and with managed care organizations that could subsequently be tested through pilot projects—and ultimately expanded nationally—in the Medicare Advantage (MA) program. AMRPA intends to share what is learned from the CCNet with HHS and other policymakers so that
we can ensure this evidence base is factored into future innovations in the Medicare program. IV. Recommendations to Overcome Barriers to Innovation: Inpatient Rehabilitation Hospital and Units Need Regulatory and Pricing Flexibility A. Regulatory Flexibility It is critical for IRH/Us to have sufficient regulatory flexibility to optimally deliver care in an evolving health care environment. To facilitate care innovation, CMS should provide IRH/Us with greater flexibility by waiving siloed regulatory requirements such as the 60 Percent Rule and the intensity of therapy requirement. CMS and the Innovation Center clearly retain the regulatory authority to waive these requirements, and the Agency has made similar concessions for other providers, particularly in the context of APMs. For example, in the Medicare Shared Saving Program (MSSP), Next Generation Accountable Care Organizations, Bundled Payment for Care Improvement (BPCI) initiative, and Comprehensive Care for Joint Replacement (CJR) program, CMS waived significant regulations such as the well-established rule necessitating a minimum three-day inpatient stay prior to covered SNF services.8 Furthermore, these regulatory changes have been favorably discussed by MedPAC in the context of reforming and advancing Medicare’s PAC payment systems.9 Unlike other hospitals participating in Medicare, in order for IRH/Us to receive payment under their prospective payment system, they must have a patient mix that fits a very specific criterion. Known as the “60 Percent Rule,” the regulation mandates that 60 percent of all IRH/U patients (across all payers) must have diagnoses derived from 13 medical conditions. This list of 13 conditions is extremely outdated, having been revised only once since its inception in 1983, and limits IRH/Us’ ability to evolve with the ever-changing medical treatment landscape. Innovations and advances in medicine over the past four decades have enabled patients with other serious diagnoses to not only survive acute care hospitalizations, but to also benefit tremendously from the intensive and multidisciplinary rehabilitation program provided in IRH/Us. However, these patients are often denied admission because they do not meet 60 Percent Rule compliance. Hence we ask that CMS grant IRH/Us relief from the 60 Percent Rule to afford IRH/Us the much-needed flexibility to expand and make care accessible to all patients who need intensive rehabilitation services. Similarly, CMS should relax the intensity of therapy requirement, also known as the “3-Hour Rule.” This rule dictates that an IRH/U must provide three hours of therapy per day, at least five days a week,
7 Id. § 1315a(b)(2)(B)(xiii). 8 E.g., Centers for Medicare and Medicaid Services, Medicare Shared Savings Program: Skilled Nursing Facility 3-Day Rule Waiver, Guidance Document v. 3 (June 2017). 9 Medicare Payment Advisory Commission, Mandated report: Developing a unified payment system for post-acute care, in Report to Congress: Medicare and the Health Care Delivery System 93 (June 2016).
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and only certain types of therapy services satisfy the requirement. To keep pace with the advances in medical rehabilitation, the requirement should, at a minimum, be changed to include additional types of therapy services and modalities. AMRPA has previously provided comments to CMS on ways to increase efficiencies and reduce redundancies for IRH/Us.10 We suggest the Department refer to those comments for our detailed recommendations regarding the 60 Percent Rule and 3-Hour Rule. B. Alternative Pricing/Reimbursement CMS encourages IRH/Us to participate in payment and care delivery innovations such as bundled payment models and other APMs. However, Medicare reimbursement for rehabilitation hospital services is very rigid, with a fixed per-patient discharge prospective payment system based largely on factors outside of the IRH/U’s control (e.g., principal diagnosis in the preceding hospitalization). In contrast, other PAC providers have a greater degree of control over their Medicare costs, namely through reducing their “units” of utilization in either a per diem payment system (nursing homes) or a fixed-length episodic payment system (home health). CMS should provide IRH/Us the flexibility to be responsive to market-based dynamics and not be constrained by an inelastic Medicare fee structure that effectively prices them out of APMs. APMs encourage providers to produce high-quality outcomes at a reduced cost. Unlike some other PAC providers, however, IRH/Us are paid on a per-discharge basis for patients and do not have the flexibility to reduce their costs, or charges to the Medicare program, in this sense. Many innovation care models therefore incentivize the risk-bearing entities to steer patients away from receiving hospital-level rehabilitation, even when it is imperative to patients’ recovery. CMS observed this very pattern in BPCI, finding that “numerous” BPCI participants “attempted to reduce episode payments by reducing institutional PAC use.”11 This has resulted in a dramatic 61 percent drop in utilization of institutional PAC services.12 For IRH/Us to be able to remain a competitive and viable PAC setting within APMs, we recommend that CMS allow IRH/Us to receive reduced reimbursements, and/or a per diem payment, or otherwise offer a discount from payments received under the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) if they so choose. Although this would likely result in IRH/ Us being paid below cost for treating some patients in these programs, the alternative—that patients are denied access to inpatient rehabilitation altogether—is far worse for Medicare patients and the IRH/U providers
who serve them. Since margins are very small or negative for the majority of IRH/Us,13 pricing flexibility must be voluntary, as should all alternative payment and care delivery concepts being tested. C. Administrative Presumption of Medicare Coverage under APMs All patients admitted to IRH/Us from upstream hospitals in an APM, regardless of whether the IRH/U is receiving IRF PPS rates or reduced reimbursement, should be presumed to be covered in the rehabilitation hospital setting. IRH/Us often are denied payment by Medicare contractors due to differing and evolving interpretations of medical necessity or technical requirements for patient stays. Appealing these decisions is resourceintensive and costly for providers. When providers bear downside financial risk for patients’ through the APM, contractors should not be permitted to deny cases on these grounds. Specifically, CMS’ contractors should not be permitted to deny payment for cases treated under APMs based on pre-payment review or post-payment reopening, unless there is evidence of fraud. APM participants are responsible for the cost and quality of care for the patients under their bundle and thus are already held accountable for their post-acute care placement decisions by virtue of the performance metrics and outcomes used in the APM. Hence if an upstream hospital chooses to discharge patients to an IRH/U, they should have full discretion to do so without Medicare contractor interference.
AMRPA again thanks HHS for its focus on innovation while mitigating burdensome regulations that hinder health care stakeholders’ ability to realize the full potential of emerging best practices. If you have any questions about our comments, please contact Carolyn Zollar, JD, Executive Vice President for Policy Development and Government Relations of AMRPA (202-860-1002, czollar@amrpa.org) or Mimi Zhang, Senior Policy and Research Analyst (202-860-1003, mzhang@amrpa.org).
Sincerely,
Richard Kathrins, Ph.D. Chair, AMRPA Board of Directors President and CEO Bacharach Institute for Rehabilitation
10 See AMRPA comments regarding CMS’ Request for Information within Medicare Program: Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2018 (CMS-1671-P), available at https://www.regulations.gov/document?D=CMS-2017-0059-0063. 11 The Lewin Group, CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 3 Evaluation & Monitoring Annual Report ES-6, 82. (Oct. 2017). 12 Id. at ES-5. Per Lewin, for BPCI Model 2 episodes where institutional PAC settings include IRH/Us, LTCHs, and SNFs. 13 For FY 2018, 43 percent of IRH/Us with available data had negative Medicare margins (below 0 percent) and 52 percent of IRH/Us had margins below 5.0 percent, based on AMRPA analysis of CMS Final Rule FY 2018 Inpatient Rehabilitation Facility Prospective Payment System rate setting files.
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CMS’ CY 2019 Proposed Rule Includes New Provisions for Home Health Agencies
Highlights: »»
Medicare payments to HHAs in CY 2019 will increase by 2.1 percent, or $400 million.
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CMS proposes changes to the home health case-mix classification system and a shift to a 30-day unit of payment with the Patient-driven Grouping Model (PDGM) in 2020.
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CMS proposes to define remote patient monitoring technology and recognize the costs as allowable administrative costs.
On July 2, the Centers for Medicare and Medicaid Services (CMS) issued the Calendar Year (CY) 2019 home health prospective payment system (HH PPS) proposed rule, which includes Medicare payment updates and proposed quality reporting changes for home health agencies (HHAs) for CY 2019. The rule also includes new case-mix methodology refinements and a change in the home health unit of payment from 60 days to 30 days for CY 2020. CMS also proposes refinements to the Home Health ValueBased Purchasing (HH VBP) Model and updates provisions under the Home Health Quality Reporting Program (HH QRP).
// CMS projects that Medicare payments to HHAs in CY 2019 would increase by 2.1 percent, or $400 million, based on the proposed policies.
The proposed rule also implements temporary transitional payments for home infusion therapy services set to begin on January 1, 2019, as required by the Bipartisan Budget Act of 2018. It also includes proposals related to full implementation of a new home infusion therapy benefit in CY 2021. CY 2019 Home Health Payment Rate Changes CMS projects that Medicare payments to HHAs in CY 2019 would increase by 2.1 percent, or $400 million, based on the proposed policies. The proposed increase reflects the effects of: a 2.1 percent home health payment update percentage ($400 million increase) a 0.1 percent increase in payments due to decreasing the fixed-dollar-loss (FDL) ratio in order to pay no more than 2.5 percent of total payments as outlier payments (a $20 million increase) a -0.1 percent decrease in payments due to the new rural add-on policy mandated by the Bipartisan Budget Act of 2018 for CY 2019 ($20 million decrease)
AMRPA Magazine / August 2018 33
The new rural add-on policy requires CMS to classify rural counties into one of three categories based on: 1) high home health utilization, 2) low population density, and 3) all others. Rural add-on payments for CYs 2019 through 2022 vary based on counties’ category classification. Case-mix Classification Changes and New Patient-driven Groupings Model (PDGM) After not finalizing the Home Health Grouping Model (HHGM) in the CY 2018 proposed rule, CMS is again proposing to implement an alternative case-mix model in the HH PPS effective January 1, 2020. The proposed Patient-driven Groupings Model (PDGM) is designed to focus more heavily on clinical characteristics and other patient information to allow payments to more closely coincide with patients’ needs. As required by the BBA of 2018, the PDGM would eliminate the use of therapy service thresholds and change the unit of payment under the HH PPS from 60-day episodes of care to 30day periods of care; these changes would be implemented in a budget neutral manner beginning CY 2020. The PDGM relies more on clinical characteristics and other patient information (such as diagnosis, functional level, comorbid conditions, source of admission) to classify patients into clinical payment groups. In total, there are 216 different payment groups in the PDGM. CMS states that using patient characteristics to place classify home health episodes is more consistent with how HHA clinicians differentiate patients, and that the PDGM would move Medicare towards a more valuebased payment system that prioritizes patient needs while also reducing the administrative burden associated with the HH PPS. To support an assessment of the effects of the proposed PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY 2019 HH PPS proposed and final rules. New Home Infusion Therapy Services Temporary Transitional Payment and Home Infusion Therapy Benefit As required by Section 50401 of the Bipartisan Budget Act of 2018 (BBA of 2018), CMS proposes to implement a temporary transitional payment for home infusion therapy services to begin January 1, 2019. The transitional payments will end the day before the full implementation of the new home infusion therapy benefit. Section 5012 of the 21st Century Cures Act (Cures Act) creates a new separate Medicare benefit category for coverage of home infusion therapy services effective January 1, 2021, which is defined as including associated professional services for administering certain drugs and biologicals through a durable medical infusion pump, training and education, and remote monitoring and monitoring services. The rule solicits comments on elements of the home infusion therapy benefit. In addition, the rule also proposes health and safety standards for home infusion therapy, an accreditation process for home infusion therapy suppliers and an approval and oversight process for the organizations that accredit home infusion therapy suppliers.
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Home Health Quality Reporting Program (HH QRP) Provisions CMS proposes to replace its current policy for removing previously adopted HH QRP measures with a policy that outlines eight consideration factors the removal of measures. CMS is also proposing to remove seven quality measures beginning in the CY 2021 HH QRP based upon one of these eight proposed measure removal factors. Lastly, CMS is proposing to update its regulations to clarify that only a portion of OASIS data is used to determine whether an HHA has satisfied the HH QRP reporting requirements for a program year. As it has done in proposed rules for other post-acute care settings this year, CMS provided update on the implementation of certain provisions of the IMPACT Act along with a discussion of accounting for social risk factors in the HH QRP. Home Health Value-Based Purchasing (HH VBP) Model CMS proposes to refine the Home Health Value-Based Purchasing (HH VBP) Model by: Removing two Outcome and Assessment Information Set (OASIS)‑based measures, Influenza Immunization Received for Current Flu Season Measure and the Pneumococcal Polysaccharide Vaccine Ever Received, from the set of applicable measures; Replacing three OASIS-based measures with two proposed composite measures on total change in selfcare and mobility; Amending how it calculates the Total Performance Scores by changing the weighting methodology for the OASISbased, claims-based, and HHCAHPS measures; and Rescoring the maximum amount of improvement points. Regulatory Burden Reduction CMS estimates that the cost impact related to OASIS item collection as a result of the proposed implementation of the PDGM and proposed changes to the HH QRP will result in a net $60 million in annualized cost savings for home health agencies, or $5,150 in cost savings per HHA per year beginning in CY 2020. In an effort to reduce physician burden unnecessary burdens for physicians, CMS is proposing to eliminate the requirement that the certifying physician estimate how much longer skilled services are required when recertifying the need for continued home health care. CMS says that this proposal is responsive to industry concerns about regulatory burden reduction and could reduce claims denials that solely result from an estimation missing from the recertification statement. CMS estimates that this proposal would result in annualized cost savings to certifying physicians of $14 million beginning in CY 2019. CMS is proposing to amend current regulations to align them with current sub-regulatory guidance to allow medical record documentation from the HHA to be used to support the basis for certification of home health eligibility, consistent with the BBA of 2018.
Request for Information on Interoperability In addition to payment and policy proposals, the rule also includes a Request for Information (RFI) for feedback on how to better achieve interoperability between providers. Specifically, CMS is requesting stakeholder feedback through a RFI on the possibility of revising Conditions of Participation (CoP) related to interoperability as a way to increase electronic sharing of data by providers. CMS has included this RFI in several payment
rules this year and AMRPA provided recommendations in response to the FY 2019 Inpatient Rehabilitation Facility PPS proposed rule. CMS will accept comments on the proposed rule until August 31, 2018.
JOIN TODAY!
EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE
AMRPA: Working Together to Preserve Preserve Access to Medical Rehabilitation AMRPA: Working Together To Access To Medical Rehabilitation Maggie Ramirez VP of Membership Services · 347-573-3732 · mramirez@amrpa.org Samantha Schwarz,· AMRPA Member Services Coordinator, 202-207-1132, sschwarz@amrpa.org
AMRPA Magazine / August 2018 35
CMS Advances Medicare Advantage Demonstration for MIPS Exemption
Highlights: »»
MIPS eligible clinicians or groups can request that CMS review the calculation of their 2019 MIPS payment adjustment factor via Targeted Review.
The Centers for Medicare and Medicaid Services (CMS) is moving forward with a demonstration to exempt clinicians who participate in payment arrangements with Medicare Advantage organizations from the Merit-based Incentive Payment System’s (MIPS) reporting requirements and payment adjustments. The Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration would exempt clinicians from MIPS reporting requirements if their arrangements with MA organizations involves an appropriate amount of value-based risk sharing for the clinician. CMS says it hopes allowing the demonstration will encourage more providers to participate in risk-bearing arrangements with MA plans. Per a notice in the July 3, 2018, Federal Register, CMS is accepting comments on the demonstration until September 4, 2018. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Provision The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides clinicians with two tracks for payment under Fee-for-Service Medicare: MIPS, which requires clinicians to report quality data to CMS and have their payment adjusted accordingly; and Advanced Alternative Payment Models (Advanced APMs), which require clinicians to take on risk for their patients’ healthcare spending. Some Medicare Advantage plans are developing innovative arrangements that resemble Advanced APMs. However, without this demonstration, physicians are still subject to MIPS even if they participate extensively in Advanced APM-like arrangements under Medicare Advantage. MIPS Payment Adjustments for 2019 Clinicians who participated in the MIPS in 2017 can view their MIPS final score and performance feedback on CMS’ Quality Payment Program website. A positive, negative or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished under the Medicare Physician Fee Schedule in 2019. Clinicians who believe an error has been made in their 2019 MIPS payment adjustment calculation may request for CMS to review their performance feedback and final score through a process called targeted review until September 30, 2018. For more information, see the Quality Payment Program Resource Library on CMS.gov.
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CMS Did Not Detect Inappropriate Durable Medical Equipment SNFs Claims, Says OIG Highlights: »»
CMS may have allowed up to $3.7 million in Medicare payments for inappropriate DME claims provided during stays in Medicaid-only nursing facilities.
The Centers for Medicare and Medicaid Services (CMS) requires skilled nursing facilities (SNFs) to provide durable medical equipment (DME) as a standard part of nursing care, and does not permit separate Medicare payments for DME except when Medicaid-only nursing facilities serve as beneficiary homes. The Department of Health and Human Services’ Office of Inspector General (OIG) monitors the appropriateness of Medicare payments for items and services, including DME, provided during stays not covered by Medicare (“noncovered stays”) in SNFs. This article highlights some of the report findings. Methods The OIG identified inappropriate claims for DME provided during noncovered stays in SNFs, and potentially inappropriate claims for DME provided during stays in Medicaid-only nursing facilities for 2015. OIG used admission and discharge dates from the Minimum Data Set (MDS) and SNF claims to document facility stay dates and identify noncovered stays. It then determined whether SNFs and DME suppliers submitted information required to facilitate proper billing for DME, and also collected information about CMS's methods to prevent processing inappropriate claims for DME in these facilities.
// The Department of Health and Human Services’ Office of Inspector General (OIG) monitors the appropriateness of Medicare payments for items and services, including DME, provided during stays not covered by Medicare (“noncovered stays”) in SNFs.
AMRPA Magazine / August 2018 37
OIG’s Findings In previous reports, the OIG found that in 2006 CMS allowed $41.2 million in Medicare payments for inappropriate claims for DME provided either during noncovered stays in SNFs ($30 million) or in Medicaid-only nursing facilities ($11.2 million). In response to OIG's work, CMS implemented a new payment edit (automated payment process) to reject claims for DME provided during noncovered SNF stays. However, OIG says that CMS did not address stays in Medicaid-only nursing facilities. Its recent report provides an update on the prior study. OIG found that: CMS's payment edits did not detect $18.4 million in Medicare payments in 2015 for inappropriate claims for DME provided during noncovered stays in SNFs. This represented 6 percent of all payments for DME during noncovered stays in SNFs. CMS uses two methods designed to identify and reject such claims, but neither method rejected the claims because SNFs and DME suppliers did not submit full and accurate information required for processing. For 72 percent of the inappropriate DME claims, DME suppliers failed to correctly code the SNF as a facility. Instead, they coded the place of service as the beneficiary's home, thus enabling the claims to bypass CMS’ detection method that rejects separate payment for most DME provided at facilities. SNFs provide primarily skilled care and thus cannot be considered beneficiary homes. For 98 percent of the inappropriate DME claims, SNFs did not submit "no payment bills," which are administrative claims that document the dates of noncovered stays and do not result in payment. No-payment bills enable another CMS process to identify noncovered stays and reject claims for DME provided during those timeframes.
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CMS may have also allowed up to $3.7 million in Medicare payments for inappropriate claims for DME provided during stays in Medicaid-only nursing facilities. Unlike SNFs, these facilities can be considered beneficiary homes if they provide primarily nonskilled care, permitting separate Medicare payments for DME. However, OIG found that CMS is unable to verify whether the facilities qualify as homes because CMS does not collect and maintain information regarding the level of care, i.e., skilled or nonskilled, that facilities provide. OIG’s Recommendations To improve detection of inappropriate DME claims, OIG recommended that CMS: 1. strengthen oversight of place-of-service codes by developing a process to determine whether DME claims with "home" as the place of service fit the circumstances permitting separate payment; 2. assess the costs and benefits of strengthening oversight of no-payment bills by developing a process to identify noncovered stays when SNFs do not submit no-payment bills; and 3. assess the costs and benefits of collecting and maintaining information regarding the level of care provided by Medicaid-only nursing facilities. CMS concurred with OIG’s recommendations. The complete report is available on OIG’s website at www.oig.gov.
Study Examines Variation in Role of LTCHs Versus SNFs in Older Adults’ Post-acute Care Highlights: »»
The strongest predictors of LTCH transfer were receiving a tracheostomy and being hospitalized in close proximity to an LTCH.
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Adjusted hospital LTCH transfer rates varied substantially.
A recent study published in JAMA Internal Medicine sought to examine factors associated with variation in transfer among hospitalized older adults to long-term acute care hospitals (LTCHs) versus skilled nursing facilities (SNFs). The study found that half of the variation in LTCH versus SNF transfer is independent of patients’ illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region. Rather, receiving a tracheostomy and being hospitalized in close proximity to an LTCH were the two strongest predictors of being discharged to an LTCH.
// The study found that half of the variation in LTCH versus SNF transfer is independent of patients’ illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region.
Methods The study participants included 65,525 hospitalized older adults aged 65 years and older who were transferred to an LTCH or SNF during fiscal year 2012 using national 5 percent Medicare data. After adjusting for case-mix, differences between patients, hospitals and regions explained 52 percent, 15 percent and 33 percent of the variation in LTCH transfer, respectively. Predictors of LTCH transfer were assessed using a multilevel mixedeffects model adjusting for patient-, hospital- and region-level factors. The authors also estimated variation partition coefficients and adjusted hospital- and regionspecific LTCH transfer rates using sequential models. Among the 65,525 hospitalized older adults (42,461 [64.8 percent] were women; 39,908 [60.9 percent] ≥85 years) were transferred to an LTCH or SNF, 3,093 (4.7 percent) were transferred to an LTCH.
AMRPA Magazine / August 2018 39
Results They authors identified 29 patient-, three hospital- and five region-level independent predictors. The strongest predictors of LTCH transfer were receiving a tracheostomy (adjusted odds ration [aOR], 23.8; 95 percent CI, 15.8-35.9) and being hospitalized in close proximity to an LTCH (0-2 versus >42 miles; aOR, 8.4, 95 percent CI, 6.1-11.5). After adjusting for case-mix, differences between patients explained 52.1 percent (95 percent CI, 47.7 percent-56.5 percent) of the variation in LTCH use. The remainder was attributed to hospital (15.0 percent; 95 percent CI, 12.3 percent-17.6 percent), and regional differences (32.9 percent; 95 percent CI, 27.6 percent-38.3 percent). Case-mix adjusted LTCH use was very high in the South (17 percent-37 percent) compared with the Pacific Northwest, North and Northeast (<2.2 percent). From the full multilevel model, the median adjusted hospital LTCH transfer rate was 2.1 percent (10th-90th percentile, 0.24 percent-10.8 percent). Even within a region, adjusted hospital LTCH transfer rates varied substantially (intraclass correlation coefficient [ICC], 0.26; 95 percent CI, 0.230.30).
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Conclusion The authors state that although many patient-level factors were associated with LTCH use, half of the variation in LTCH versus SNF transfer is independent of patientsâ&#x20AC;&#x2122; illness severity or clinical complexity, and is better explained by where the patient was hospitalized and in what region, with far greater LTCH use in the South. Even among hospitals in regions with similar LTCH access, there was considerable variation in LTCH use. The authors note that more research is needed to better understand the differences between LTCH versus SNF placement and to optimize post-acute care for older adults. For more information, see the study abstract, Factors Associated with Variation in Long-term Acute Care Hospital versus Skilled Nursing Facility Use Among Hospitalized Older Adults, March 2018, JAMA Internal Medicine.
CMS Launches Data Element Library Supporting Interoperability
Highlights: »»
The public can view the specific types of data that CMS requires post-acute care providers to collect as part of the health assessment of their patients.
The Centers for Medicare and Medicaid Services (CMS) announced the agency’s first Data Element Library (DEL). The DEL is a new CMS database that supports the exchange of electronic health information that has been under development for several years. Using this database, the public can view the specific types of data that CMS requires post-acute care (PAC) providers to collect as part of the health assessment of their patients. These assessments include questions and response options (data elements) about patients, including demographics, medical problems and other types of health evaluations.
// The DEL is a new CMS database that supports the exchange of electronic health information which has been under development for several years.
IMPACT Act Requirements The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 requires that CMS make interoperable standardized patient assessment and quality measures data to allow for exchange of data among PAC and other providers to facilitate coordinated care and improved outcomes. CMS has developed the DEL to satisfy the Congressional mandate. CMS expects to update the DEL over time as new and modified standardized data elements, new assessment instrument versions, and new and updated health information technology (HIT) mapping are added. Many of these data elements have been standardized and health care facilities can integrate the information into their medical record systems, and is then used for multiple purposes, such as payment by CMS, quality measurement and quality improvement. In CMS’ view, the DEL will make it easier to incorporate standards and data elements used by PAC providers into electronic health records (EHRs).
AMRPA Magazine / August 2018 41
Assessment Items/HIT CMS assessment items included in the DEL are derived from the: Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Long-term Care Hospital Continuity Assessment Record and Evaluation Data Set (LCDS) Skilled nursing facility Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Home health Outcome and Assessment Information Set (OASIS) Hospice Item Set (HIS) Functional Assessment Standardized Items (FASI) (Currently being tested with long-term services and supports (LTSS) beneficiaries in some states)
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The DEL does not contain patient health data but does includes PAC assessment questions and their response options, as well as other associated details including the assessment version, item labels and status, etc. The DEL also includes health information technology (health IT) standards that support the collection of health information. Because the DEL now puts these standards and data elements all in one place, CMS says that it will be easier for health IT vendors to incorporate them into electronic health records (EHRs) that are used by PAC providers, ultimately allowing health information to flow more easily from one provider to another, particularly when patients transition among PAC settings. To view the CMS Data Element Library, visit: del.cms.gov.
Study Evaluates the Effectiveness of Nonsurgical Options to Treat Knee Osteoarthritis
Highlights: »»
The authors analyzed improvement of pain and function. For pain reduction, cortisone injections provided the greatest short-term pain relief.
»»
Naproxen was the nonsurgical treatment ranked highest for probability for improving function.
An estimated 45 percent of people are at risk of developing knee osteoarthritis (OA) in their lifetime and effective nonsurgical treatments are often needed for the management of symptoms. According to a research article published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), the nonsteroidal anti-inflammatory drug (NSAID) naproxen was ranked most effective in individual knee OA treatment for improving both pain and function, and is considered a relatively safe and lowcost treatment method. In addition to NSAIDs, other nonsurgical treatments for knee OA supported include:
// The study is the first comprehensive mixed-comparison analysis comparing best-evidence scientific research and excluded lower quality studies that can bias the outcomes...
strength training low-impact aerobic exercises weight loss in individuals with a body mass index over 25 The new research analyzed data from multiple trials to determine the relative effectiveness of various nonsurgical treatments for knee OA. The study is the first comprehensive mixed-comparison analysis comparing bestevidence scientific research and excluded lower quality studies that can bias the outcomes, according to lead author and orthopedic surgeon David Jevsevar, MD, MBA. The study utilized a statistical ranking technique to provide evidence regarding which of the most common NSAIDs are most likely to decrease pain and improve function, and sought to fill in the gaps in evidence for more inconclusive treatments such as hyaluronic acid (HA), platelet-rich plasma (PRP), and corticosteroids.
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Methods The researchers designed a network meta-analysis to determine clinically relevant effectiveness of: acetaminophen ibuprofen intra-articular (IA) or joint injections of cortisone platelet-rich plasma (PRP) hyaluronic acid (HA) several NSAIDs, such as naproxen, celecoxib, and diclofenac both oral and IA placebo The authors analyzed 53 randomized controlled trials that examined knee OA treatments for at least 28 days and included a minimum of 30 participants per study group. Knee OA treatments were ranked on a scale of one to five, with one being the most effective. Results The study found that: For pain reduction, cortisone injections provided the greatest short-term (four to six weeks) pain relief, followed by ibuprofen, PRP injections, naproxen and celecoxib. Naproxen ranked the highest for probability for improving function, followed by diclofenac, celecoxib, ibuprofen and PRP injections.
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Naproxen ranked as most effective among conservative treatments of knee OA and should be considered when treating pain and function because of its relative safety and low cost. However, the authors acknowledge that there were instances of inconsistency in the design and duration among studies that potentially affect uniform data inclusion. HA injections did not achieve a rank in the top five treatments for pain, function, or combined pain and function. Although the use of NSAIDs for arthritic conditions such as knee OA has potential risks, including heart attack and stroke, existing evidence indicates that naproxen has less potential for adverse cardiovascular events. “Because knee OA has both a high disease burden and high treatment costs, additional prospective studies using similar outcomes, timelines and measures of clinically important changes are needed,” explained Jevsevar. “While the information in this analysis is helpful to physicians, patients also can benefit from these findings and use it with their doctors to weigh all possible treatment options.” For the full study, Mixed Treatment Comparisons for Nonsurgical Treatment of Knee Osteoarthritis: A Network Meta-analysis, see the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), May 1, 2018 - Volume 26 - Issue 9 - p 325–336.
Report Outlines Ways to Improve Health and Functioning Outcomes for Children with Disabilities
Highlights: 
Achieving specific near- and longterm goals and coordination of care within and across service sectors is integral to encouraging healthy growth and development for children with disabilities.
A substantial number of children have at least one chronic health condition and any of these conditions are associated with disabilities and that may interfere with their usual activities, such as play or leisure activities, attending school and engaging in family or community activities, according to a recent report published by the National Academies of Sciences, Engineering, and Medicine (National Academies). In their most severe forms, such disorders are serious lifelong threats to their social and emotional well-being and quality of life, and anticipated adult outcomes such as for employment or independent living. However, pinpointing the prevalence of disability among children in the U.S. is difficult, as conceptual frameworks and definitions of disability vary among federal programs, according to the report. While a variety of services and programs exist to support the needs of children with disabilities and their families, a focus on achieving specific near- and long-term goals that help prepare for adulthood and coordination of care within and across service sectors are integral to encouraging healthy growth and development. The National Academies convened a committee to develop a report that examined federal,
// While a variety of services and programs exist to support the needs of children with disabilities and their families, a focus on achieving specific near- and long-term goals that help prepare for adulthood and coordination of care within and across service sectors are integral to encouraging healthy growth and development. AMRPA Magazine / August 2018 45
state and local programs and services in a range of areas, such as health care, special education, transition to adulthood, vocational rehabilitation and social needs care. Although children with disabilities have a diverse range of health conditions, they share many of the same needs; therefore, the committee used a non-disease-specific approach to assessing programs and services designed to improve children’s outcomes. The life-course perspective acknowledges that early experiences impact later experiences and long-term outcomes, and the committee recommends that near- and long-term goals be linked to the attainment of desired longterm outcomes and that services are individualized based on an assessment of the child’s and family’s specific needs. Several other characteristics contribute to the effectiveness of these programs and services, such as:
Lack of preparedness for transitioning to adult services and programs Gaps in continuity of care This service fragmentation places a burden on families of children with disabilities who need access to and coordination of high-quality services. Furthermore, the evidence base for programs and services aimed at improving outcomes for children with disabilities is limited because of a number of factors, such as: Limited longitudinal data on health and functioning outcomes A lack of rigorous evaluation of existing programs and services
Engaging children and families in their care Helping them navigate and connect with the array of available supports Conducting rigorous, systematic evaluation and continuous improvement of services The report found that there is a variety of gaps and limitations that create barriers to access and variable quality of services, such as: Socio-demographic and socio-economic disparities State variation in the implementation of federal programs Fragmentation of services Insufficient workforce capacity and development
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The inability to isolate impacts when children use different programs and services over time as their needs evolve The committee outlined opportunities to improve the collection and sharing of data and to inform future research efforts on trajectories, outcomes and interventions, in order to develop innovative and collaborative approaches for promoting healthy growth and development for children with disabilities and supporting their families. For more information, see National Academies of Sciences, Engineering, and Medicine. 2018. Opportunities for Improving Programs and Services for Children with Disabilities. Washington, DC: The National Academies Press. https://doi.org/10.17226/25028.
Hospital-at-Home Care Bundled with a 30-Day Post-Acute Transitional Care Episode was Associated with Better Patient Outcomes
Highlights: »»
Hospital-at-home care bundled with a 30-day episode of post-acute transitional care may be a safe and effective alternative to inpatient care for some patients.
Hospital-at-home (HaH) care provides acute hospital-level care in a patient’s home as a substitute for traditional inpatient care. In September 2017, the Physician-Focused Payment Model Technical Advisory Committee recommended implementation of an alternative payment model (APM) for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care.” A recent study sought to find the association of providing hospital-athome care bundled with a 30-day postacute period of home-based transitional care with clinical outcomes and patients’ experiences compared with traditional inpatient care. The services provided during the 30-day post-acute transitional period include scheduled post-discharge visits, urgent visits by community paramedics as needed, and care coordination with the patient’s regular care providers. The study reported on the outcomes associated with this new payment model for HaH care.
// The services provided during the 30-day post-acute transitional period include scheduled post-discharge visits, urgent visits by community paramedics as needed, and care coordination with the patient’s regular care providers.
The participants in the case-control study included eligible HaH care patients with a concurrent control group of hospital inpatients from emergency departments (EDs) and residences from November 18, 2014, to August 31, 2017. HaH patients were 18 years or older with fee-for-service Medicare and acute medical illness requiring
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inpatient-level care, limited to certain diagnoses. Control patients met HaH eligibility but refused participation or were seen in the ED when a HaH admission could not be initiated. Primary outcomes were acute period length of stay (LOS), allcause 30-day hospital readmissions and ED visits, admissions to skilled nursing facilities (SNFs), referral to a certified home health agency (HHA), and patient experiences with care. Analyses accounted for nonrandom selection using inverse probability weighting. Results The study found that compared with patients receiving inpatient care, patients receiving hospital-at-home care had shorter length of stay, lower rates of 30-day hospital readmission, ED visits, and SNF admissions; and better ratings of care. There were no differences in the rates of adverse events. Among the 507 patients enrolled (mean [SD] age, 74.6 [15.7] years; 68.6 percent women), data were available on all patients 30 days post discharge. HaH patients (n = 295) were older than controls (n = 212) and more likely to have a pre-acute functional impairment. HaH patients had shorter LOS (3.2 days vs 5.5 days; difference, −2.3 days; 95 percent CI, −1.8 to −2.7 days; weighted P < .001); lower rates of readmissions (8.6 percent [25] vs 15.6 percent [32]; difference, −7.0 percent; 95 percent
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CI, −12.9 percent to −1.1 percent; weighted P < .001), ED revisits (5.8 percent [17] vs 11.7 percent [24]; difference, −5.9 percent; 95 percent CI, −11.0 percent to −0.7 percent; weighted P < .001), and SNF admissions (1.7 percent [5] vs 10.4 percent [22]; difference, −8.7 percent; 95 percent CI, −13.0 percent to −4.3 percent; weighted P < .001); and were also more likely to rate their hospital care highly (68.8 percent [119] vs 45.3 percent [67]; difference, 23.5 percent; 95 percent CI, 12.9 percent to 34.1 percent; weighted P < .001). There were no differences in referrals to certified home health agencies (HHAs). Conclusion The study authors concluded that hospital-at-home care bundled with a 30-day post-acute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization. They add that the model warrants consideration for addition to Medicare’s current portfolio of shared savings programs. For the study abstract, see Association of a Bundled Hospitalat-Home and 30-Day Post-acute Transitional Care Program with Clinical Outcomes and Patient Experiences, JAMA Internal Medicine Published online June 25, 2018.
Latest Research Findings
Electrical Sensory Input in Routine Rehabilitation Can Improve Early Post-stroke Lower-extremity Impairment Clinical studies have shown that sensory input improves motor function when added to active training after neurological injuries in the spinal cord. Researchers aimed to determine the effect on the motor function of extremities following the addition of an electrical sensory modality without motor recruitment before or with routine rehabilitation for hemiparesis after stroke.
sensory inputs, when paired with routine therapy, improved peak torque dorsiflexion (mean difference [MD] 2.44 Nm, 95 percent confidence interval [CI] 0.26-4.63). On subgroup analysis, the combined therapy yielded a significant difference in terms of sensory stimulation without motor recruitment only on the Timed
The researchers conducted a comprehensive systematic review and meta-analysis by searching databases from 1978 to 2017 for reports of randomized controlled trials or controlled studies of patients with a clinical diagnosis of stroke who underwent 1) transcutaneous electrical nerve stimulation (TENS) or peripheral electromyographytriggered sensory stimulation over a peripheral nerve and associated muscles or 2) acupuncture to areas that produced sensory effects, without motor recruitment, along with routine rehabilitation. Outcome measures were motor impairment, activity and participation outcomes defined by the International Classification of Functioning, Disability and Health. The search yielded 11 studies with data that could be included in a meta-analysis. Electrical
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Up and Go test in the chronic phase of stroke (MD 3.51sec, 95 percent CI 3.05-3.98). The spasticity score was reduced but not significantly (MD -1.11 points, 95 percent CI -2.35-0.13). The researchers found that electrical sensory input can contribute to routine rehabilitation to improve early post-stroke lowerextremity impairment and late motor function, with no change in spasticity. Prolonged periods of sensory stimulation such as TENS
combined with activity can have beneficial effects on impairment and function after stroke. For the study, see Adding Electrical Stimulation During Standard Rehabilitation After Stroke to Improve Motor Function. A Systematic Review and Meta-analysis. Ann Phys Rehabil Med. 2018 Jun 26. pii: S1877-0657(18)31408-8. doi: 10.1016/j. rehab.2018.06.005. [Epub ahead of print].
Maximum Walking Speed Could Be an Independent Prognostic Factor for Composite Vascular Events in Mild Ischemic Stroke A recent cohort study sought to identify the prognostic value of physical activity-related factors as well as known vascular risk factors for vascular events in mild ischemic stroke. Study participants included patients with acute ischemic stroke and transient ischemic attack with modified Rankin scale scores ranging from 0 to 2. Enrolled patients were followed up for composite vascular events as primary outcomes up to three years post discharge. Primary outcomes included stroke and cardiovascular death, hospitalization due to stroke or transient ischemic attack (TIA) recurrence, cardiovascular disease, and peripheral artery disease (PAD). During hospitalization, known vascular risk factors such as previous history of vascular events, stroke subtype, white matter
lesions, and ankle-brachial index were assessed. Moreover, at the time of discharge, physical activity-related factors such as maximum walking speed, handgrip strength, knee extensor isometric muscle strength, anxiety and depression were assessed as potential predictors. A total of 255 patients (175 men, median age 70 years) were enrolled in the study. The Kaplan-Meier estimates of cumulative risk of composite vascular events at one-, two- and three-years were 9.6 percent, 14.4 percent, and 15.2 percent, respectively. After multivariate analysis, cerebral white matter lesions of periventricular hyperintensity (grade=3; hazard ratio: 2.904; 95 percent confidence interval: 1.160 to 7.266; p=0.023) and maximum walking speed (<1.45m/s; hazard ratio: 2.232; 95 percent confidence interval: 1.010 to 4.933; p=0.047) were identified as significant independent predictors of composite vascular events. Study results indicated that maximum walking speed could be an independent prognostic factor for composite vascular events in mild ischemic stroke. For the study, see Maximum Walking Speed at Discharge Could be a Prognostic Factor for Vascular Events in Patients with Mild Stroke: A Cohort Study. Arch Phys Med Rehabil. 2018 Jun 26. pii: S0003-9993(18)30384-8. doi: 10.1016/j.apmr.2018.05.025. [Epub ahead of print].
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Obesity Linked to Health Problems after Acute Rehabilitation for Traumatic Brain Injury Being overweight and obesity are associated with chronic disease risks for survivors of moderate to severe traumatic brain injury (TBI) especially at longer follow-up times, reports a study in the July/August issue of the Journal of Head Trauma Rehabilitation (JHTR). The findings highlight the need for a proactive approach to managing weight and related health conditions in long-term TBI survivors.
reported in the general U.S. population (over 70 percent). The authors attributed this to several reasons and called for further examination – for example, a higher rate of health complications, rehospitalizations, medication side effects or death among individuals who were already obese at the time of TBI and thus were excluded from the follow-up study.
The study included 7,287 adults with TBI who had undergone inpatient acute rehabilitation. Care was provided by rehabilitation centers participating in the Traumatic Brain Injury Model Systems (TBIMS) program, sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR).
During the early recovery period, patients may lose weight due to increased metabolic rate and other physical effects of TBI. In the later phases, weight gain may occur due to a wide range of factors including medical conditions, medications, cognitive or behavioral changes, physical limitations and lack of transportation or other resources.
About three-fourths of patients were men; the average age all participants was 46 years. The relationship between body weight and functional and health outcomes was assessed from one to 25 years after TBI. At the most recent follow-up, 23 percent of TBI survivors were classified as obese, 36 percent as overweight, 39 percent as normal weight, and three percent as underweight.
Based on the large-scale TBIMS database, the new study confirms that being overweight or obese is associated with significant health problems for survivors of moderate to severe TBI who require acute rehabilitation. The researchers note some important limitations of their study, including the lack of information on the timing of weight problems and associated health conditions.
Patients under age 30 or over age 80 were less likely to be overweight or obese. While the percentage of overweight patients was relatively stable, the obesity rate increased over time – especially five years or longer after TBI.
For more information, see Obesity and Overweight Problems Among Individuals 1 to 25 Years Following Acute Rehabilitation for Traumatic Brain Injury: A NIDILRR Traumatic Brain Injury Model Systems Study. The Journal of Head Trauma Rehabilitation: July/ August 2018 - Volume 33 - Issue 4 - p 246–256.
Being overweight or obese was strongly associated with several chronic health conditions, including high blood pressure, heart failure and diabetes. Overweight/obese patients also rated themselves as having poorer general health. The frequency of seizures – a common problem among TBI survivors – was also related to differences in body weight and health status. The overall rate of overweight/obesity in the TBI patients (59 percent) was lower than
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Physical Activity Interventions May Be More Effective After Completing Inpatient Rehabilitation Phase Researchers recently conducted a study to improve physical activity (PA) counseling, well-being and clinical outcome after total knee and hip arthroplasty (TKHA) through tailored activity counseling during inpatient rehabilitation. The study participants were 65 patients (aged 70.4 ± 7.3 years, BMI 28.5 ± 4.3) starting inpatient rehabilitation after primary knee or hip arthroplasty due to osteoarthritis and were recruited and pseudorandomized into an intervention group (IG) and a control group (CG). Twice a week, the IG was encouraged to increase their daily step count by 5 percent. PA, e.g., number of steps, step frequency or active minutes, as measured by step activity monitoring. Wellbeing and clinical outcome were assessed using the SF-36, Oxford Knee/Hip Score and Global Rating of Change. Procedures were conducted at the onset of inpatient rehabilitation, and repeated one and six months after inpatient rehabilitation. Data sets were obtained from 49 patients (IG: n = 23, CG: n = 26). Both groups significantly increased their number of daily steps from the 1 month to the 6 months follow up after rehabilitation: CG: 9019 (95 percentCI: 7812, 10,226), IG: 9280 (7972, 10,588) and CG: 10921 (9571, 12,271), IG: 11326 (9862, 12,791) respectively. Additionally, well-being and clinical outcome improved significantly in both groups. No significant differences in physical activity, clinical outcome and well-being were found between the groups.
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The study concluded that PA counseling during inpatient rehabilitation did not improve physical activity, well-being and clinical outcome in patients with primary knee or hip arthroplasty in addition to the rehabilitation program. However, PA interventions may be more effective after the completion of the inpatient rehabilitation phase. For the study, see Impact of a tailored activity counseling intervention during inpatient rehabilitation after knee and hip arthroplasty - an explorative RCT. BMC Musculoskelet Disord. 2018 Jun 30;19(1):209. doi: 10.1186/s12891-018-2130-7. PubMed PMID: 29960605.
AMRPA wants to ensure that our members are active participants in shaping their federal representation in Congress. To do so, we are continuing to provide updates on upcoming Congressional elections. Below you’ll find information on primary elections taking place in August and September, as well as online resources where you can find additional information on voting, Congressional representatives, and primary election results. The following 14 states will be holding primary elections in August:
Tennessee – August 2, 2018 Nine House seats are up for election: seven incumbents and two opens seats. There is one Senate seat up for election.
Kansas – August 7, 2018 There are four House seats in the delegation: three incumbents and one open seat. There are no Senate seats up for election.
Michigan – August 7, 2018 There are 14 House seats up for election: 12 incumbents and two open seats. There is one Senate seat up for election.
Missouri – August 7, 2018 Eight House seats are up for election. All incumbents are running for reelection. There is one Senate seat up for election.
Washington – August 7, 2018 There are 10 House seats in the delegation: nine incumbents and one open seat. There is one Senate seat up for election.
Hawaii – August 11, 2018 Two House seats are up for election: one incumbent and one open seat. There is one Senate seat up for election.
Connecticut – August 14, 2018 Five House seats are up for election: four incumbents and one open seat. There is one Senate seat up for election.
Minnesota – August 14, 2018 There are eight House seats up for election: six incumbents and two open seats. There is one Senate seat up for election.
Vermont – August 14, 2018 There is one House seat in the delegation. The incumbent is running for reelection. There is one Senate seat up for election.
Wisconsin – August 14, 2018 Eight House seats are up for election: seven incumbents and one open seat. There is one Senate seat up for election.
Alaska – August 21, 2018 There is one House seat in the delegation. The incumbent is running for reelection. There are no Senate seats up for election.
Wyoming – August 21, 2018 There is one House seat up for election. The incumbent is running for reelection. There is one Senate seat up for election.
Arizona – August 28, 2018 Nine House seats are up for election: six incumbents and three open seats. There is one open Senate seat up for election.
Florida – August 28, 2018 There are 27 House seats in the delegation: 23 incumbents and four open seats. There is one Senate seat up for election.
AMRPA Magazine / August 2018 53
The following five states will be holding primary elections in September:
Massachusetts – September 4, 2018 Nine House seats are up for election: eight incumbents and one open seat. There is one Senate seat up for election.
Delaware – September 6, 2018 There is one House seat up for election. The incumbent is running for reelection. There is one Senate seat up for election.
Be sure to visit the AMRPA Congressional Elections webpage for more information and primary election results: http://amrpa.org/Advocacy/2018-CongressionalElections. If you have any questions or feedback, please contact Catherine Beal at cbeal@amrpa.org or (202) 8601006. For more information on your federal representatives, please visit the following websites:
New Hampshire – September 11, 2018
Find your House representative here: www.house.gov/ representatives/find-your-representative and Senators here: www.senate.gov/general/contact_information/ senators_cfm.cfm.
There are two House seats in the delegation: one incumbent and one open seat. There are no Senate seats up for election.
For more voting information, and to find out if you are registered, please visit: www.usa.gov/voting.
Rhode Island – September 12, 2018 Two House seats are up for election. Both incumbents are running for reelection. There is one Senate seat up for election.
New York – September 13, 2018 There are 27 House seats up for election: 26 incumbents and one open seat. There is one Senate seat up for election.
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Visit eRehabData.com to learn more, or contact Sam Fleming at sam@erehabdata.com to receive a free demo. Without losing any historical data, our staff help you migrate to the only patient assessment system that is trusted, owned, used, and supported by the medical rehabilitation industry. 56 AMRPA Magazine / August 2018