AMRPA Magazine - February 2019 by AMRPA

February 2019 â&#x20AC;¢ Vol. 22, No.2

February 2019 â&#x20AC;˘ Vol. 22, No. 2

The official publication of the American Medical Rehabilitation Providers Association (AMRPA)

Table of Contents Letter from the Chair

Legislative Update

ACA Ruled Unconstitutional Case is Stayed Pending Appeal

New Case Mix Group Lessons Learned from the Field

On the Road to a Unified Post-Acute Care Prospective Payment System

MedPAC to Recommend 5 Percent Payment Cut for IRFs in FY 2020

CMS Issues Clarification on the Role of Therapy Students in Hospitals

AMRPA Responds to OIG Report Critical of Rehabilitation Hospitals and Units

Study Examines the Association of Medicaid Expansion with Access to Rehabilitative Care

Brian McGowan AMRPA Design and Layout

Higher Nurse Staffing Levels Linked with Reduced Length of Stay, Adverse Events and Mortality

AMRPA Magazine, Volume 22, Number 2

Accountable Care Organizations Can Improve Results by Focusing on High-risk Patients, Commonwealth Fund Reports

GAO Issues Report on Medicare Payments for Long-term Care Hospitals that Specialize in Spinal Cord Treatment

OIG Issues Report on Adverse Events in Long-term Care Hospitals

High-Cost Medicare Beneficiaries Spend More on Outpatient Care and Medications

CHCS Develops Checklist to Assist States in Adopting Value-Based Payment Models for Home and Community- Based Services

Study Examines PROMIS Use During Outpatient Orthopedic Visits

Latest Research Findings

AMRPA Congressional News Center

Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Director Carolyn Zollar, MA, JD AMRPA Executive Vice President for Government Relations and Policy Development Mimi Zhang AMRPA Senior Policy and Research Analyst Patricia Sullivan AMRPA Senior Editor Lovelyn Robinson AMRPA Researcher and Editor

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: Julia Scott, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1110, Email: jscott@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 ÂŠ2019 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

AMRPA Magazine / February 2019

Letter from the Chair

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

Join us for the AMRPA Spring Conference and Congressional Fly-In I gave serious consideration to writing this month’s letter on a number of topics. Worthy of review were our ongoing actions to address the Department of Health and Human Services Office of Inspector General’s report, “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medical Coverage and Documentation Requirements.” I also gave thought to addressing the latest Medicare Payment Advisory Commission recommendations to reduce Medicare payments for inpatient rehabilitation hospitals by 5 percent in fiscal year (FY) 2020. It was also hard not to give a full response to another article on accountable care organizations (ACOs), “Spending Patterns Among Medicare ACOs That Have Reduced Costs (Shultz J, DeCamp M, Berkowitz SA, 2018).” The article noted that reduced costs by ACOs in 2014 and 2015 were due to reductions in skilled nursing facility (SNF) and inpatient admissions, not by the cost per hospitalization or SNF admission. Each of these topics was well-suited for an editorial response. Except for the article, all of these topics are currently being actively addressed, including recent membership correspondence. At this time, it seems more critical to encourage our members to join us in Washington this year for our annual AMRPA Spring Conference and Congressional Fly-In. This year’s conference, like years past, is an excellent opportunity to interact with federal policy makers and Washington, DC, leaders. Bringing government representatives and AMRPA members together is as important as ever. Given the discussions in Washington, the ongoing challenges we face from auditors, regulators and policy makers seeking to possibly impose barriers to admissions, we need a strong, cohesive voice. We need your help to ensure that these policy makers hear of the value and importance of the medical rehabilitation field directly from those on the front line. In addition to the Leadership Forum, the Medical Directors Symposium specifically provides our physician leadership with the knowledge and networking opportunities they need to stay informed on the latest issues in the field. First hand feedback from some of last year’s attendees spoke to the value they derived from the sessions. Physicians have a powerful voice and message that needs to be heard. Members of Congress appreciate our medical directors’ clinical expertise in explaining how policies have real life implications to patient care. We hope that you will encourage physicians to attend our forum and fly-in. As one of our association’s flyers noted, “You have much to gain by joining us, and more to lose by staying on the sidelines.” We do hope to see you March 10-12 for our 2019 Spring Conference and Congressional Fly-in being held at the Ritz Carlton Pentagon City, Arlington, Virginia. For more information, I hope you will visit www.amrpa.org.

REFERENCE Schult, J., DeCamp, M., & Berkowitz, S.A. (2018, Nov/Dec). Spending Patterns Among Medicare ACOs That Have Reduced Costs. J Healthcare Management, 63 (6), 374-381.

AMRPA Magazine / February 2019

2019 Spring Conference & Congressional Fly-In March 10-12, 2019 • Ritz Carlton Pentagon City Hotel • Arlington, VA

AMRPA Magazine / February 2019

Legislative Update

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

Highlights:

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The 116th Congress convened on January 3, 2019, with a diverse class of nearly 100 new members. A recordbreaking 127 women are now serving in Congress.

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The House consists of 235 Democrats and 199 Republicans; and the Senate consists of 45 Democrats, 2 Independents (who caucus with the Democrats) and 53 Republicans.

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After 35 days, the President and Congressional Leadership came to an agreement to end the shutdown with legislation to re-open the federal government for three weeks (until February 15), as negotiations continue on border wall funding.

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Democrats are expected to sharpen their focus on health care access and consumer costs in 2019. One possible area of bipartisan cooperation may be legislation to address so-called “surprise billing” for patients.

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The White House Office of Management and Budget continues to review a number of rules from the Centers for Medicare and Medicaid Services (CMS), including regulations that address health IT, Medicare and Medicaid.

AMRPA Magazine / February 2019

116th Congress Convenes in the Midst of Partial Government Shutdown The 116th Congress convened on January 3, 2019. Members of Congress were sworn-in by newly elected Speaker of the House Nancy Pelosi (D-Calif.), leader of the new Democratic majority in the House. She won the Speakership with 220 votes; 15 Democrats did not vote for Pelosi, including several freshman lawmakers who had made campaign promises to oppose her. In her opening speech, Speaker Pelosi pledged to lower health care costs and prescription drug prices, and protect people with preexisting medical conditions. The House approved portions of a rules package (H. Res. 6) for the 116th Congress that extended most provisions in place during the previous session while making several notable changes. The first title of the package, which passed 234-197 on a mostly partyline vote, would allow Congress to intervene in court cases related to the Affordable Care Act, such as Texas v. Azar, or any other case that involves the constitutionality or legality of the law. The rules measure also includes strengthened “PAYGO” provisions requiring any legislation that would increase the deficit to be offset by tax increases or mandatory spending cuts. The package also clarifies that any legislation must be made public 72 hours prior to a House vote, and it establishes a new Select Committee on the Climate Change Crisis. The partial government shutdown lasted five weeks before President Trump and Congressional leaders finally came to an agreement on re-opening the shuttered departments. The president was insistent on more than $5 billion for construction of a border wall but Democrats would only offer about $1.3 billion – an extension of existing funding levels. House Democrats began pressuring Republicans by advancing individual appropriations bills to reopen portions of the government, but the administration would not accept a piecemeal reopening without border wall funding. Further, Senate Republicans declined to take up any legislation that is not supported by the President. This shutdown broke the record for the longest in history at 35 days (previously the record was 21 days during the Clinton administration). While the Department of Health and Human Services (HHS) has full-year funding through September 30, 2019, a number of other departments were affected by the shutdown, including Agriculture, Commerce, Homeland Security, Housing and Urban Development, Interior, Justice, and the Treasury. The shuttered agencies employ about 800,000 federal workers who went without pay until the shutdown ended The shutdown will also slow down the FY 2020 Appropriations process, which begins in eight months. On January 25, during his announcement about reopening the federal government, the president demanded that Congress send him bipartisan legislation in three weeks to address the “border crisis.” He warned that another partial federal government shutdown was imminent if border wall legislation was not passed by February 15. He

has also floated the idea of declaring a national emergency in order to build a border wall using Department of Defense funding without explicit authorization from Congress. Such a move would almost certainly be challenged in federal court, although the courts historically have been deferential to the Executive Branch in matters of national security. Rep. Mac Thornberry (R-Texas), Ranking Member on the House Armed Services Committee, also has seriously questioned the use of Department of Defense funding for non-defense purposes. Congressional Committees Gear Up for Legislative Action The House Energy and Commerce Committee announced that it will hold hearings this month to examine the ACA court case and its impact, as well as a hearing on the Trump Administration's family separation policy. Rep. Frank Pallone (D-New Jersey) will chair the House Energy and Commerce Committee, while Rep. Greg Walden (R-Oregon) now is the Ranking Member. Rep. Anna Eshoo (D-Calif.) is expected to lead the Health Subcommittee. The House Democratic Steering and Policy Committee has recommended that the following members be added to the Committee: Rep. Nanette Barragan (D- Calif.), Rep. Robin Kelly (D-Ill.), Rep. Marc Veasey (D-Texas), Rep. Tom O’Halleran (D-Ariz.), Rep. Darren Soto (D-Fla.), Rep. Don McEachin (D-Va.), Rep. Lisa Blunt Rochester (D-Del.), and Rep. Ann McLane Kuster (D-N.H.). Rep. Richie Neal (D-Mass.) and Rep. Kevin Brady (R-Texas) will lead the House Ways and Means Committee. The House Democratic Steering and Policy Committee has recommended that the following Member s be added to the Ways and Means Committees: Rep. Stephanie Murphy (D-Fla.), Rep. Brad Schneider (D-Ill.), Rep., Gwen Moore (D-Wis.), Rep. Dan Kildee (D-Mich.), Rep. Don Beyer (D-Va.) , Rep. Steven Horsford (D-Nev.), Rep. Brendan Boyle (D-Pa.), Rep. Jimmy Panetta (D- Calif.), Rep. Tom Suozzi (D-N.Y.), and Rep. Dwight Evans (D-Pa.). Chairman Neal is pushing to move a tax extenders package in the near future which may include a repeal of the medical device excise tax. Progressive Democrats also are leading the push to advance “Medicare for All” proposals. While the Democratic Caucus remains divided on the issue, making it unlikely that legislation will move this session, Democratic leaders have expressed support for holding hearings on the issue. Senate Republicans announced their committee assignments for the 116th Congress. Senators James Lankford (R-Okla.), Steve Daines (R-Mont.), and Todd Young (R-Ind.) will join the Senate Finance Committee. Their new Democratic colleagues, who were announced last month, include Sens Maggie Hassan (D-N.H.) and Catherine Cortez Masto (D-Nev.). Committee Chairman Chuck Grassley (R-Iowa) recently laid out his policy priorities, which include consideration of drug pricing proposals and an examination of waste, fraud and abuse in Medicare and Medicaid, including improper payments. Grassley has a long history of using his oversight power in the health care space, and he noted his concerns with the quality and staffing of nursing homes and his interest in looking at how anti-competitive consolidations affect Medicare and Medicaid payments.

Senators Mitt Romney (R-Utah) and Mike Braun (R-Ind.) have been added to the Senate Health, Education, Labor and Pensions (HELP) Committee roster. As governor of Massachusetts Romney oversaw the nation’s first health care insurance exchanges. He will now have purview over Medicaid and the ACA’s exchanges as a member of the HELP Committee. Committee Chairman Lamar Alexander (R-Tenn.) released a letter to health policy experts, regulators and providers, seeking recommendations on next steps to address rising health care costs. The committee held a series of hearings on health care costs in 2018 and is expected to continue its work in the 116th Congress. Texas v. Azar Update On December 14, Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas ruled in Texas v. Azar that the ACA’s individual mandate is unconstitutional because Congress repealed the penalty for noncompliance with the mandate in the 2017 tax reform law. Judge O’Connor reasoned that, because the 2012 Supreme Court ruling upholding the individual mandate’s constitutionality hinged on it being a valid exercise of Congress’s taxation authority, the removal of the “tax” (i.e., the penalty for noncompliance) left no constitutional leg on which the mandate could stand. Judge O’Connor further concluded that the individual mandate is “essential” to, and therefore inseverable from, the ACA and declared the entire statute invalid. The White House issued a statement shortly after the decision was released indicating that the law will remain in place pending appeal. The Centers for Medicare and Medicaid Services (CMS) also said that the agency will continue to implement the ACA and specifically noted that the work of the Center for Medicare and Medicaid Innovation (CMMI), which was authorized and funded by the ACA, will not be affected. To remove all doubt, on December 30, 2018, Judge O’Connor issued an order staying the effect of the prior order pending appeal. The appeal to the Fifth Circuit Court of Appeals is being led by California Attorney General Xavier Becerra and several other state Democratic attorneys general. Whatever the Fifth Circuit decides, the case ultimately could make its way to the U.S. Supreme Court, raising the possibility of a ruling in 2020 during the presidential campaign. The Supreme Court’s rulings often apply a presumption of severability, meaning that when the Court finds a portion of a law unconstitutional, it tries to preserve the rest of the law as much as possible. The outlook for legislative action in the 116th Congress is unclear at present. The president was quick to declare victory soon after the decision, describing the ACA an “unconstitutional disaster” and calling for Congress to pass a new health care law to replace it. Senate Minority Leader Chuck Schumer (D-N.Y.), meanwhile, said the ruling was “based on faulty legal reasoning,” while Speaker Pelosi has called the district court’s ruling “absurd” and an “assault on people with pre-existing conditions and Americans’ access to affordable health care.”

AMRPA Magazine / February 2019

CMS Finalizes Overhaul of Medicare’s National ACO Program On December 21, CMS released a final rule overhauling the Medicare Shared Savings Program (MSSP). The new direction for the program, dubbed Pathways to Success, makes a number of changes to Medicare Accountable Care Organizations (ACOs). The agency moved forward with reducing the amount of time ACOs can spend in the MSSP before taking on financial risk. Beginning in 2019, ACOs can remain a one-sided risk model for two years, instead of six years before taking on risk. Current ACOs in a one-sided model must start taking on risk in one year. Stakeholders pushed back on the shortened time frame in public comments, but CMS Administrator Seema Verma explained, “… over time those ACOs that take accountability for costs perform better than those that do not.” Hospitals and health systems advocated for a more gradual pathway to take on financial risk due to the necessary investment and time needed to build a successful ACO. The regulation increased the shared savings rate for ACOs that do not take on risk to 40 percent, which is down from the current 50 percent, but up from the proposed regulation’s 25 percent rate. The final rule also allows for payment for telehealth services furnished to prospectively assigned beneficiaries receiving telehealth services in non-rural areas, and allows beneficiaries to receive certain telehealth services at their home, to support care coordination across settings. CMS finalized the policy to allow eligible ACOs under performance-based risk to use the program’s existing SNF three-day rule waiver. CMS also amended the existing SNF three-day rule waiver to allow critical access hospitals (CAHs) and other small, rural hospitals operating under a swing bed agreement to be eligible to partner with eligible

AMRPA Magazine / February 2019

ACOs as SNF affiliates for purposes of the SNF three-day rule waiver. CMS estimates that the final rule will save Medicare $2.9 billion over 10 years. *** The funding battle continues to be mired in disagreement over money for the president’s proposed wall along the Mexican border, a non-starter for Democrats. The partial shutdown has made it difficult for Congress and the new Democratic majority to hit the ground running with its policy priorities. However, now that a temporary compromise is in place, we can expect fast and furious Congressional developments, as well as regulatory movement. With more than 100 new representatives in the 116th Congress, we encourage AMRPA members to take advantage of this opportunity to educate members of Congress on how critically important and medically necessary rehabilitative care is for its patients and the unique role of rehabilitation hospitals in the continuum of care. Please reach out to your newly elected members and ask them to visit your hospitals and outpatient facilities – these types of visits help cultivate strong Congressional champions for the field! We also urge AMRPA members to register for the upcoming Leadership Conference in Fly-In in March. We will help set up meetings for you and your colleagues on Capitol Hill with your members of Congress and senators, and provide you with talking points on the fields’ most pressing policy issues. Be on the lookout for an upcoming AMRPA webinar to help prep for the Fly-in and convey AMRPA’s important message to Congress!

AMRPA Magazine / February 2019

ACA Ruled Unconstitutional Case is Stayed Pending Appeal

Peter W. Thomas, Principal, The Powers Law Firm

On Friday, December 14, 2018, a Texas federal judge issued a ruling that found the entire Patient Protection and Affordable Care Act (“ACA”) unconstitutional.1 The lawsuit, Texas v. United States, was brought by Texas Attorney General Ken Paxton, along with 17 other attorneys general and two governors, as the latest judicial attempt to challenge the constitutionality of the ACA.2 Judge Reed O’Connor of the Northern District of Texas ruled in favor of the plaintiffs, holding that the individual mandate is no longer valid under Congress’s taxing power. Judge O’Connor also found the individual mandate to be “essential” and “inseverable” from the rest of the ACA, invalidating the entirety of the federal health care law. An injunction was not granted at the time of the decision, however, the judge subsequently stayed the holding in the case pending appeal. This means there will not be any immediate disruptions in the U.S. health care insurance system. Following is a brief background of the lawsuit, an overview of the decision, and the implications it may have on the health care insurance system.

Megan LaSuer, JD, MHA Associate, The Powers Law Firm

Background When the ACA was enacted in 2010, the new law included a provision known as the individual mandate, which required most Americans “to maintain minimum essential coverage” or pay a tax penalty.3 Two years after the ACA’s passage, the Supreme Court ruled on the constitutionality of the individual mandate in National Federation of Independent Businesses (“NFIB”) v. Sebelius.4 The Supreme Court found the mandate penalty to be constitutional under Congress’s taxing power because it would raise “at least some revenue for the Government.”5 However, after several failed attempts by Congress to repeal core provisions of the ACA, in December 2017, Congress used the Tax Cuts and Jobs Act (TCJA) to zero out the tax penalty for failing to purchase minimum essential coverage, effectively eliminating the enforcement provisions of the individual mandate beginning in 2019.6 While the TCJA eliminated the penalty, Congress left the rest of the ACA provisions in place, including the requirement that individuals maintain certain minimum coverage. On February 26, 2018, 18 Republican state attorneys general and two governors7 filed this lawsuit, asking Judge O’Connor to prohibit the government “from implementing, regulating, enforcing, or otherwise acting under the authority of the ACA.”8 Oral arguments were held on September 5, in which the plaintiffs argued that when the tax penalty is zeroed out, the individual mandate will no longer raise revenue and therefore will no longer function as a tax. Without this tax function, plaintiffs contend that the Supreme Court’s interpretation of the mandate in NFIB no longer applies and the law is, therefore, unconstitutional. The plaintiffs also argued that the mandate is essential to the other provisions of the ACA, such as the guaranteed issue and community

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rating provisions, and therefore the entire law must be declared unconstitutional, including protections against pre-existing condition exclusions. In a highly unusual move, then-U.S. Attorney General Jeff Sessions announced that the Department of Justice (DOJ) would not defend the constitutionality of the individual mandate, breaking from the longstanding tradition for the executive branch to uphold and defend existing U.S. statutes.9 In May 2018, the court allowed California Attorney General Xavier Becerra and 16 Democratic state attorneys general to intervene in the case and act as defendants.10 Amicus briefs opposing the lawsuit were also filed by the American Medical Association, the American Hospital Association, America’s Health Insurance Plans, and other health care stakeholders. The intervenor-defendants argued that although the TCJA eliminated the tax penalty for individuals who forego health insurance, the individual mandate remains constitutional, and if found not to be constitutional, is still severable from the rest of the ACA.11 The Decision In early September, Judge O’Connor held a hearing addressing the plaintiffs’ request to halt the ACA immediately. Judge O’Connor issued his decision on December 14, siding with the plaintiffs and finding that the TCJA rendered the entire ACA unconstitutional and struck down the law. Judge O’Connor reached three conclusions in this ruling: 1) the plaintiffs have standing to sue; 2) the individual mandate is no longer permissible under Congress’s taxing power and is therefore unconstitutional; and 3) the individual mandate is not severable from the ACA, making the entire law invalid, not just the individual and small group market provisions, but the entire 1,100 page law. Judge O’Connor concluded that the individual mandate can no longer be considered a valid exercise of Congress’s tax power because it does not meet the factors to be considered a tax, as laid out in NFIB. Now that the penalty will be zeroed out, Judge O’Connor held that “the Individual Mandate no longer ‘triggers a tax’ beginning in 2019,”12 and is now simply a “standalone command” that “does nothing.”13 Judge O’Connor’s decision breaks from Supreme Court precedent regarding severability of the individual mandate, finding that both the 2010 Congress and the 2017 Congress intended for the mandate to be inseverable from the entire ACA. The judge relied on congressional findings enacted when the ACA was passed that noted how the mandate is essential to creating effective health insurance markets and regulating economic activity, and that the absence of the mandate “would undercut federal regulation of the health insurance market.”14 Accordingly, because the 2010 Congress found the individual mandate to be “essential,” Congress also intended it to be inseverable from the ACA. During oral argument, the intervenor-defendants argued that the 2017 Congress intended to allow the ACA to remain as good law. Their argument was based on the fact that when Congress passed the TCJA, only the individual mandate tax penalty was eliminated and that Congress intended to leave the rest of the ACA standing. Judge O’Connor disagreed with this interpretation of what Congress intended and found

that by declining to repeal any part of the ACA, including the individual mandate, “the 2017 Congress further entrenched the intent manifested by the 2010 Congress” that the mandate remains essential to the entirety of the ACA.15 In reaching this conclusion, Judge O’Connor ignored the fact that Congress also amended additional parts of the ACA after the TCJA was passed and the intervenors’ argument that Congress would not make amendments to “a statute that it believed had been invalidated in total.”16 Judge O’Connor did not grant an injunction at the time of the holding, leading to concern that the decision would effectively halt implementation of the law. Following the decision, however, the Department of Health and Human Services issued a press release stating that it “will continue administering and enforcing all aspects of the ACA as it had before the court issued its decision.”17 More recently, the judge granted a motion by the defendant-intervenors staying the impact of the holding pending appeal. Implications and Backlash If this decision is upheld and the ACA is struck down, there would be far-reaching effects across the U.S. health care system, especially in the individual and small group markets but in other areas as well. The ACA impacts the structure of Medicaid and the Indian Health Service, as well as the types of drugs individuals can access. The Centers for Medicare and Medicaid Innovation (CMMI) was authorized under the ACA and the Older Americans Act was reauthorized. Provisions such as the ACA’s ban on annual and lifetime limits, coverage of preventative services without cost-sharing, and the requirement that insurers provide coverage to young adults up to age 26 under their parents’ plans would be eliminated. Protections for people with preexisting conditions, which was a key point in the November midterm elections, would also be eliminated. Many legal experts and congressional leaders have acknowledged that there are faults in Judge O’Connor’s legal analysis. Shortly after the opinion was issued, the intervenordefendants announced their intention to appeal the decision, and pledged to “continue to fight in court for the health and well-being of all Americans.”18 Congressional Democrats have also voiced their opposition to this ruling. Then-House Minority Leader Nancy Pelosi (D-Calif.) issued a statement that “the House of Representatives will move swiftly to formally intervene in the appeals process to uphold the life-saving protections for people with pre-existing conditions.”19 In fact, in her first day as Speaker of the House of the 116th Congress, Speaker Pelosi took the first steps to implement her commitment to intervene in the lawsuit. As it turns out, swift House action to intervene in the suit is not necessary. The partial government shut-down has led to the appeal in this case being placed on hold until the Department of Justice is funded with appropriations for FY 2019. Next Steps: Appealing the Decision This case leaves the future of the ACA unclear; however the intervenor-defendant attorneys general moved swiftly to start the appeal process. On December 17, they filed an expedited motion

AMRPA Magazine / February 2019 11

asking Judge O’Connor to issue an order clarifying that, given this decision, the ACA will continue to be enforced while the case is being appealed.20 The motion also asked that the judge certify his opinion so it can be appealed to the Fifth Circuit.21 Shortly thereafter, the Department of Justice and the plaintiff states also filed briefs, agreeing with the intervenor-defendants that the current status of the ACA remains unchanged and that Judge O’Connor should certify his opinion so that it may proceed to appeal.22 On December 30, 2018, Judge O’Connor issued a stay and partial final judgment, which will allow the parties to appeal the decision and ensures that the ACA will remain in effect during the appeal.23 Whether this appeal makes it past the Fifth Circuit is unclear, but many legal analysts believe it will not. Given the overreach the judge seemed to employ in this case, many believe the case will be overturned. However, whether the case is reversed or upheld, the losing side is sure to appeal to the Supreme Court. If this occurs, the case would not reach the Supreme Court until 2020, making it a key issue during the next presidential election. Endnotes 1. Texas v. United States (Memorandum Opinion), No. 4:18-cv00167-O (W.D. Tex. Dec. 14, 2018). 2. Complaint, Texas v. United States, No. 4:18-cv-00167-O (W.D. Tex. Feb. 26 2018). 3. 26 U.S.C. § 5000A(a). 4. Nat’l Fed’n of Indep. Businesses v. Sebelius, 567 U.S. 519 (2012). 5. Id. at 564. 6. Tax Cuts and Jobs Act, Pub.L. 115–97, 131 Stat. 2054 (2017). 7. The Plaintiffs include the Attorneys General of Texas, Wisconsin, Alabama, Arkansas, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Missouri, Nebraska, North Dakota, South Carolina, South Dakota, Tennessee, Utah, and West Virginia & the Governor of Maine and Governor of Mississippi. 8. Complaint at 32. 9. Letter from Jeff Sessions, U.S. Attorney General, to Paul Ryan, Speaker of U.S. House of Rep. (June 7, 2018), https://www. justice.gov/file/1069806/download.

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10. The Intervenor-Defendant states are California, Connecticut, Delaware, Hawaii, Illinios, Kentucky Massachusetts, Minnesota, New Jersey, New York, North Carolina, Oregon, Rhode Island, Vermont, Virginia, Washington, and the District of Columbia. 11. Transcript of Record at 37-38, Texas v United States. No. 4:18-cv-00167-O (W.D. Tex. Dec. 14, 2018). 12. Memorandum Opinion at 27. 13. Id. at 34. 14. 42 U.S. Code § 18091(2)(H). 15. Memorandum Opinion at 37. 16. Federal Defendants’ Memorandum in Response to Plaintiffs’ Application for Preliminary Injunction, Texas v United States. No. 4:18-cv-00167-O at 18 (W.D. Tex. Dec. 14, 2018). 17. Statement from the Department of Health and Human Services on Texas v. Azar (Dec. 17, 2018) https://www.hhs.gov/ about/news/2018/12/17/statement-from-the-department-ofhealth-and-human-services-on-texas-v-azar.html. 18. Statement from Attorney General Becerra Denouncing Court Ruling Declaring the ACA Unconstitutional (Dec. 14, 2018) https://oag.ca.gov/news/press-releases/attorneygeneral-becerra-denounces-court-ruling-declaring-acaunconstitutional. 19. Statement from Representative Nancy Pelosi on District Judge Ruling in GOP Lawsuit Against Pre-Existing Condition Protections and the Affordable Care Act (Dec. 15, 2018) https://www.democraticleader.gov/newsroom/121418-4. 20. Motion for Expedited Consideration, Clarification or Stay, and Entry of Partial Final Judgment for Intervenor-Defendants, Texas v. United States, No. 4:18-cv-00167-O (Dec. 17, 2018). 21. Id. 22. Federal Defendants’ Response to Intervenor-Defendants’ Motion for Expedited Consideration, Clarification or Stay, and Entry of Partial Final Judgment or Certification Under 28 U.S.C. § 1292(b), Texas v. United States, 4:18-cv-00167-O (Dec. 21, 2018). 23. Texas v. United States (Order Granting Stay and Partial Final Judgment), No. 4:18-cv-00167-O (W.D. Tex. Dec. 30, 2018).

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2020 Fall Educational Conference & Expo Renaissance Dallas Hotel Dallas, TX October 11-14, 2020

2021 Fall Educational Conference & Expo JW Marriott Turnberry Isle Miami, FL October 24-27, 2021

2022 Fall Educational Conference & Expo St. Louis Union Station Hotel St. Louis, MO October 9-12, 2022

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New Case Mix Group Lessons Learned from the Field

Are you prepared to convert to the new case mix groups (CMGs) arriving in October 2019? Over the past few months, much of my consulting work has focused on helping providers evaluate their current status and identifying areas for improvement ahead of the imminent changes. In this article I will share with you some lessons learned from this process.

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

// All nurses and therapists will need to participate in scoring in order to get a true picture of the patient’s baseline performance before intervention was initiated.

1. Your documentation is not ready. How can I say this with certainty? Because I have not seen anyone build documentation to gather sections GG and H data with the intent of capturing the burden of care based on the CMS definitions. This is partly because the definitions continue to be clarified. The Centers for Medicare and Medicaid Services (CMS) uses the term “usual status” when they talk about what value should be reported for the quality indicator items. Based on the initial CMS training on the descriptions, we concluded that CMS intended for providers to gather data for three days and then report the usual performance. Current CMS training explains that “usual status” should be recorded, but providers should be measuring this before intervention has been initiated. Does your documentation account for that? The bladder and bowel (section H) items are still a three-day assessment period, but the section GG items call for the patient’s “usual status” to be recorded prior to the initiation of intervention. Most of the issues I find in documentation are due to complications with assigning the items for completion. In other words, the vast majority of providers are assigning the section H bladder and bowel continence questions to nursing; the section GG self-care items to be completed on the Occupational Therapy evaluation; and the section GG mobility items to be completed on the Physical Therapy evaluation. To ensure that we are gathering data prior to the initiation of intervention and reflecting the burden of care, nurses will need to participate in scoring section GG items. So if you have included the questions in the therapy assessments, you will need to modify the documentation to have a flowsheet that is accessible to nurses. 2. All nurses and therapists will need to participate in scoring in order to get a true picture of the patient’s baseline performance before intervention was initiated. As I said above, based on initial CMS training for the descriptions, we concluded that they intended for providers to gather data for three days and then report the usual performance. To be clear, most providers have not been doing that. Rather, most providers gathered data in the therapy assessments and not after that unless the item was not tested on the first day. I believe that education will need to be conducted with nurses on the nuances of the new

AMRPA Magazine / February 2019 15

scoring breakdown and special considerations for each item. The most important time to gather scores will be day 1 by nurses and day 2 in the therapy evaluations. Beyond that, intervention will have been introduced for many items, so the therapist or nurses will not get a baseline score for the patient.

3. Education is pivotal. Nurses will require education on the nuances of the new scoring breakdown and special considerations for each item. Therapists will require training on special considerations for each item with more emphasis on how each item differs from the current, similar FIMTM items – this is especially true for the self-care items. In case you did not notice the difference in those two statements, the training for a nurse should be different from the training for a therapist. This goes against everything I have ever believed in terms of training for FIMTM. I have always advocated that interdisciplinary training was the best way to expose everyone to the same message and to foster understanding of the hurdles that a nurse faces as compared to a therapist, and vice versa. In the case of section GG, the scoring breakdown, items and what to consider are all new to the nurses so it is necessary to have more intentional education on these items. I do not want to imply that nurses are the only people who need training. Rather, the occupational and physical therapists also need training because the capturing of the burden is often overlooked. Review the IRF-PAI Training Manual and the Q&As from CMS’ provider training to make sure that you are clear on what is included in the scoring of each section GG item. Train staff accordingly.

4. Evaluate how your scores are gathered. It is important to have a system in place that will differentiate what coding an “88” means. CMS has indicated that

16 AMRPA Magazine / February 2019

we have three days to test each section GG and H item. If an item is not addressed on days 1 or 2, then it may be tested on day 3. If your flowsheet includes the responses 1-6, 7, 88, 9 and 10 only, then there is no way to convey that an item was simply not tested that day. Blanks can lead to an incomplete assessment. If your PPS coordinator spent countless hours tracking down data for missing items to avoid submitting an incomplete IRF-PAI to CMS in the early days of the section GG and H items, then there’s a good chance that you have likely conditioned therapists to not leave anything blank. We still need a score for each item. If you did not get to assess each item today because the patient was generally too sick to participate, you might have scored an 88. This 88 is different from the patient not being able to complete the assessment due to their physical condition or medical status. To differentiate these scenarios from an 88, consider adding a score in your flowsheet to reflect that an item was not attempted. 5. Start now. This is not a task that can be put off until the summer. Since modifications to the electronic medical record (EMR) take time, you cannot afford to wait to start evaluating and planning until the spring. In an ideal timeline, EMR changes should be scoped during the first quarter of 2019. Education should be developed during the second quarter, and conducted during July and August. You should roll out the new EMR documentation and begin documenting on sections GG and H in early September as some of those patients may not be discharged until October 1 or later. For questions or for more information on how our consulting services can help you with the transition, feel free to reach out to us at assistance@eRehabData.com.

On the Road to a Unified Post-Acute Care Prospective Payment System

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

It is January 1, 2025. The newly designated post-acute care providers (PACPs) are waking up to start being paid under the new Unified Post-Acute Care Prospective Payment System (UPAC PPS) and their new designation. Inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), skilled nursing facilities (SNFs) and home health agencies (HHAs) no longer exist as separate entities. They have all become PACPs and will be paid under the new system with some variation in the treatment of PACPS-H (formerly HHAs). The new system includes a patient classification system such as the case mix groups (CMGs) or home health resource groups (HHRGs), a unit of payment covering a stated period of time, specified clinical services, some adjustments for providers’ unique characteristics, new conditions of participation, and various special adjustments or payment policies such as wages, rural status, teaching, outliers, and low income percentage. There are also multiple quality measures to examine the outcomes achieved by the UPAC PPS. The new system will be distributing more than $60 million in Medicare Part A fee-for-service payments. Now, any reader who has read this far probably realizes that the above is total fiction and an estimate regarding the impending changes in the payment system for the four post-acute care providers. The closer reality is that SNFs will start to be paid under a new payment system – the Patient Driven Payment Model – on October 1, 2019 (FY 2020). A new payment system has also been developed for home health agencies – Patient Driven Groupings Model (PDGM) – and will be implemented January 1, 2020. IRFs anticipate new CMGs also effective October 1, 2019 (FY 2020). Hence, as a result of these changes, there will be radical payment changes while we are on the road to developing a UPAC PPS. This article is intended to provide a general overview on where post-acute care (PAC) is on the road to developing a UPAC PPS. It is clearly no longer a gleam in some policy analyst’s eye and has not been for a long time. The path for such a system started most recently with the Post-Acute Care Payment Reform Demonstration (PAC PRD) authorized by the Deficit Reduction Act of 2005. In addition to developing the Continuity Assessment Record and Evaluation (CARE) tool, that project also examined PAC episodes and risk adjustment that received little notice. At the same time, the work and analysis from the PAC PRD is the progenitor of subsequent legislation on quality and payment development activity. As noted, the initial outcome of the project was the CARE tool for assessing patients at various points in their PAC stays. However, in lieu of grafting the entire CARE tool upon the PAC community, the Centers for Medicare and Medicaid Services (CMS) has taken various measures or elements from it and amended the existing patient assessment instruments. They amended assessment instruments such as the Minimum Data Set (MDS), and Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI)

AMRPA Magazine / February 2019 17

initially for purposes of quality measurement in 2012 pursuant to the Affordable Care Act (ACA) requirement and last year for IRF payments in the FY 2019 IRF Prospective Payment System (PPS) rule. Another step down this road is the Improving Medicare PostAcute Care Transformation (IMPACT) Act of 2014. It is a threelegged stool focusing on the development of quality measures in specific domains, in addition to the ACA quality measures and standard patient assessment data elements (SPADE) also specifically outlined in domains and the UPAC PPS. For IRFs and several other PAC providers, CMS has almost completed its quality work, and is concluding a national project in developing the SPADE items. AMRPA has been actively involved in both arenas and their development since their inception. A noted third area focuses on the development of the UPAC PPS. In pursuing this goal the IMPACT Act requires several reports. The first was a report by the Medicare Payment Advisory Commission (MedPAC) published in June 2016. In developing the report, MedPAC was to utilize the framework from the PAC PRD and its data, to evaluate and recommend features of a prospective payment system that establishes payment rates according to characteristics of individuals such as cognitive ability and functional status and impairments, as opposed to setting and its impact. The proposal has not received much attention from other policy makers. While AMRPA has not taken a position on the report, there are concerns about MedPAC’s desire to implement the system by 2021, not include functional data, base it solely on administrative data, and utilize, at least in its initial analysis, data used in the PAC PRD in 2008, among other concerns. Under the MedPAC proposal, payment would be redistributed and IRFs would lose 12 percent. Since its initial publication, MedPAC has used the subsequent years, 2017 and 2018, to explore implementation issues associated with the proposal such as sequential stays and aligning statutory and regulatory requirements, among others. However, and perhaps fortunately, the MedPAC report is not the sole report required under the IMPACT Act. The Secretary of Health and Human Services (HHS) is to send a report to Congress on a technical prototype of a UPAC PPS. In this prototype, payment is to be based on individual characteristics, such as cognitive ability, functional status and impairments, in lieu of the setting in which they are furnished. The system is also to account for the clinical appropriateness of services and is also to account for standard patient assessment data. Finally, it is to further clinical integration, recommend which current regulations should be altered, provide an analysis of the impact of the system on beneficiary cost sharing, access to care and choice of setting, and project the reduction of payments attributable to the new UPAC PPS. So what is the status of the development of the UPAC PPS, pursuant to the IMPACT Act mandate? Over a year ago, CMS and the Office of the Assistant Secretary for Planning and Evaluation (ASPE) entered into a contract again with RTI International to work on developing the UPAC PPS. Many of the researchers on this project also participated in the PAC PRD project. In its first year, RTI and the agencies developed a work plan and timeline. In September 2018, RTI held a Technical Expert Panel (TEP) to which 18 AMRPA Magazine / February 2019

AMRPA was invited to participate. The purpose of this panel was to discuss foundational questions to inform exploratory research on the potential to develop a technical prototype for a UPAC PPS for home health agencies (HHAs), skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and LTCHs. Stakeholders were invited to participate in this meeting to discuss policy considerations in the design of a UPAC PPS where payments are based on beneficiary characteristics rather than PAC setting. RTI notes that approximately half of Medicare beneficiaries with an inpatient hospitalization are discharged to a PAC provider and PAC expenditures in fee-for-service Medicare were more than $60 billion in 2016 (MedPAC, 2018). Though there is some overlap in the characteristics of patients treated across PAC settings, Medicare payments for PAC services differ significantly across PAC settings. Over the course of the next year, RTI will work with CMS and ASPE to develop analyses to inform a prototype for a UPAC PPS. These analyses will be informed by the foundational questions and issues discussed at the meeting. These included defining the time period, defining costs across providers, identifying claimsbased and assessment-based variables to predict costs across providers, and ensuring quality of care and beneficiary choice. Numerous additional questions were also discussed, such as: Should there be near-term and longer-term considerations? What clinical services should be included? What conditions should be included? All or select conditions? What are the considerations regarding provider certification? What changes could be made to current regulations? Many of these questions are classic ones that have to be addressed when considering the structure of a traditional prospective payment system. One outstanding question is when is the report due? When will a UPAC PPS be implemented? No specific date is slated. The law says “not later than two years after the date the Secretary has collected two years of data on quality measures… in consultation with MedPAC and stakeholders, submit a report to Congress.” And once the report is sent to Congress, Congress would have to enact legislation to implement any UPAC PPS. AMRPA’s new Unified Post-Acute Care Prospective Payment System Workgroup has been exploring these questions in order to respond to RTI. The workgroup is chaired by Board of Directors member Suzanne Kauserud, Vice President of the Inpatient Continuing Care Division with Atrium Health. RTI asked for responses to a series of these and other questions by January 25, 2019, so the work group is hard at work in the New Year! Clearly, RTI’s work and the resulting technical UPAC PPS prototype required by the statute will be critical to IRFs’ future. AMRPA will be actively involved in its development. According to CMS, RTI will hold two additional TEP meetings in 2019. We invite any comments on such a system from our readers. As always, stay tuned.

AMRPA Magazine / February 2019 19

MedPAC to Recommend 5 Percent Payment Cut for IRFs in FY 2020

In December, the Medicare Payment Advisory Commission (MedPAC) met to consider draft recommendations for payment updates and other policy issues for Medicare-certified providers for federal fiscal year (FY) 2020.

Mimi Zhang, AMRPA Senior Policy and Research Analyst

Highlights: »»

MedPAC expected to recommend a 5 percent payment cut for inpatient rehabilitation hospitals/units in FY 2020.

»»

In 2017, Medicare FFS comprised 58.8 percent of all IRF patients.

As this magazine went to press, and pending a formal vote by the Commission in January, MedPAC is expected to recommend that Congress reduce the Medicare payment rate for inpatient rehabilitation hospitals and units (IRFs) by five percent in FY 2020. This would be the third year in a row that MedPAC recommends a 5 percent cut for the sector; Congress has not implemented the recommendation in past years. In addition, MedPAC would also reiterate its standing recommendations for the Secretary of the Department of Health and Human Services to expand the highcost IRF outlier payment pool and to conduct targeted medical reviews to study the interrater reliability of patient assessments. State of the Field In 2017, 1,178 IRFs accounted for $7.7 billion of Medicare spending, down from $7.9 in 2016. The average payment per case in 2017 was $20,300 (up from $19,714 in 2016). Medicare fee-for-service (FFS) volume declined somewhat in 2017 compared to recent years: there were 380,000 cases (down from 391,000 cases in 2016), and FFS comprised 58.8 percent of all admissions, which had been holding at around 60 percent in years past. The number of FFS cases per 10,000 also dropped to 98.6 from 100.9. The average occupancy rate remained steady at 65 percent and the average length of stay was 12.7 days. Between 2016 and 2017, the number of freestanding IRFs increased by 2.2 percent and the number of for-profit providers grew 5.9 percent. The number of hospitalbased units and non-profit IRFs declined 1.7 percent and 2.2 percent, respectively. MedPAC reported that the sector’s access to capital remains adequate as in past years, and observed that large IRF companies are pursuing vertical integration strategies, expanding service lines across the PAC continuum, and engaging in joint ventures with acute care hospitals. Medicare Margins Financial performance continues to vary across the sector. MedPAC estimates that the aggregate overall Medicare margin in 2019 will be 11.6 percent. In 2017, the actual aggregate Medicare margin was 13.8 percent (Note: MedPAC had previously projected that 2017 margins would be 14.3 percent). MedPAC also reported a new data point, all-payer margins, which they described as “robust” for freestanding hospitals. MedPAC is not able to calculate all-payer margins for rehabilitation units.

20 AMRPA Magazine / February 2019

The margins by facility type are as follows: IRF Medicare Margins, 2017 % of IRFs

% of cases

2017 Margin

Change from 2016 (percentage points)

All IRFs

100%

13.8%

0.8

Freestanding

24%

52%

25.5%

0.0

Units

76%

48%

1.5%

0.3

Non-profit

57%

39%

2.2%

0.2

For-profit

33%

54%

23.8%

-0.1

All-Payer Margins for Freestanding IRFs, 2017

10.4%

IRF Medicare Marginal Profit, 2017 (profit of admitting one additional patient) Marginal profit

Change from 2016

Freestanding

40.9%

0.0

Units

19.4%

0.1

With regard to marginal profits, MedPAC maintains that beneficiary access will be secure because both freestanding and hospital-based IRFs are incentivized to admit additional Medicare patients. Cost and Payment Growth From 2009 to 2015, aggregate IRF Medicare payments have grown faster than costs. However, cost growth began outpacing payment growth in 2016, a trend that MedPAC expects will continue. Payment growth will be further limited for 2018 and 2019 because payment updates were statutorily set and are below market basket levels.

Source: MedPAC

According to MedPAC, the primary driver of variation in provider margins is facility cost, and contributing factors may include: Fewer economics of scale: units tend to be smaller with lower occupancy, with 67 percent having fewer than 25 beds. The majority of units are non-profit and may be less focused on cost control and revenue growth. From 2009-2017, costs in units went up 21 percent versus 10 percent in freestanding hospitals. Units tend to have a different mix of patients: 24 percent of patients in units are admitted for stroke versus 17 percent in freestanding hospitals. 10 percent of patients in units are admitted for “Other neurological” conditions versus 19 percent in freestanding IRFs. Units may have different assessment and coding practices. Quality Since 2012, IRF quality performance has remained stable or improved, according to six risk-adjusted measures developed for MedPAC by a contractor: IRF Medicare Marginal Profit, 2017

2012

2017

Gain in motor function, in points

22.1

24.0

Gain in cognitive function, in points

Source: MedPAC

From 2009-2015, the difference in per-case cost combined with payment growth contributed to growing margins, with aggregate IRF margins being above 13 percent for the past three years.

3.5

3.9

Rate of discharge to community

74.3%

76.0%

Rate of discharge to SNFs

6.9%

6.8%

Potentially avoidable hospitalization during IRF stay

2.8%

2.6%

Potentially avoidable hospitalization within 30 days after IRF discharge

4.8%

4.7%

Relatively Efficient IRFs This year, MedPAC presented a study of “relatively efficient” IRFs. MedPAC already uses this approach to assess acute care hospitals and skilled nursing facilities (SNFs). Relatively efficient providers are defined as providers with consistently

AMRPA Magazine / February 2019 21

low costs and high quality. They must be in top third performance on costs or MedPAC’s quality metrics every year over a three-year lookback period, and cannot have poor performance (be in the bottom third) on cost or quality metrics in any years. MedPAC finds that freestanding and for-profit facilities were “disproportionately represented” among relatively efficient providers. However, about half of all relatively efficient IRFs are also units. Compared to other IRFs in 2017, relatively efficient IRFs: Were larger and had higher occupancy rates, leading to 18 percent lower costs. The Medicare margins for relatively efficient IRFs was 16.5 percent versus to 1 percent for other IRFs.

Had a different mix of patients. Relatively efficient IRFs had a smaller share of stroke cases and higher share of Other neurological condition cases. Had 9 percent lower readmission rates and 35 percent lower rates of discharge to SNFs. Next Steps Pending a formal vote on January 17, 2019, MedPAC’s recommendations will be issued in mid-March in its annual Report to Congress on Medicare payment policies.

CMS Issues Clarification on the Role of Therapy Students in Hospitals During a National Provider Call for rehabilitation hospitals and units on November 15, 2018, officials from the Center for Medicare and Medicaid Services (CMS) provided a novel interpretation of the role that therapy students may play in providing care to patients in rehabilitation hospitals. The interpretation of regulations provided by CMS was concerning because it would have sharply limited the participation of therapy students in hospitals, even as part of their official clinical training. After a collaborative effort among AMRPA, the American Physical Therapy Association (APTA), the American Speech Hearing Association (ASHA) and the American Occupational Therapy Association (AOTA), CMS reversed its stance on the matter. Most notably, CMS says student therapists may participate in therapy provided in a hospital, if the student is appropriately supervised, and that the time spent with the student may count toward satisfying intensity of therapy requirements for rehabilitation hospitals and units. Here is a key excerpt from the clarification issued by CMS: “Regarding the IRF intensive rehabilitation therapy program requirement in 42 CFR 412.622(a)(3)(ii), CMS's current policy does not prohibit the therapy services furnished by a therapy student under the appropriate supervision of a qualified therapist or therapy assistant from counting toward the intensive rehabilitation therapy program. However, IRFs provide a very intensive hospital level of rehabilitation therapy to some of the most vulnerable patients. To ensure the health and safety of this vulnerable population, CMS expects that all student therapy services will be provided by students under the supervision of a licensed therapist allowed by the hospital to provide such services.”

22 AMRPA Magazine / February 2019

AMRPA Responds to OIG Report Critical of Rehabilitation Hospitals and Units

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

Highlights: »»

»»

AMRPA joined by American Academy of Physical Medicine and Rehabilitation and Federation of American Hospitals in objecting to OIG conclusion Comprehensive response submitted to OIG and policy makers

In October 2018 the Department of Health and Human Services’ Office of Inspector General (OIG) released a report titled Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements. The report audited 220 Medicare claims from Inpatient Rehabilitation Hospitals or Units (IRH/Us) from 2013, and found that 175 of the sampled claims were paid in error. Of the 175 claims the OIG deemed to be improper, it stated that 146 were improper because the patient lacked the medical needs and functional rehabilitation goals necessary for IRF admission. The OIG also noted that a very high number of the claims had documentation deficiencies. In total, the OIG concluded that this audit showed that 135 IRH/Us were improperly paid $8,325,940 for the stays examined. The OIG extrapolated its sampled findings to the entire universe of Medicare IRF claims for 2013 and concluded that in 2013 Medicare paid $5.7 billion for care to beneficiaries that was not reasonable and necessary. The OIG report also recommended that Medicare implement a prior authorization pilot program for IRF claims, as well as increase its post-service audits of IRF claims, among other recommendations. Upon receipt of this report, AMRPA immediately began a fact-finding operation to analyze and dissect the report. The association asked two other stakeholder organizations – the American Academy of Physician Medicine and Rehabilitation (AAPM&R) and the Federation of American Hospitals (FAH) – to join AMRPA in a response to this report. The three organizations produced a comprehensive response to the report, and delivered it to the OIG and key policy makers in other agencies and Capitol Hill. The organizations also held an in-person meeting with Medicare officials in January to reiterate our numerous concerns with the report.

// Upon receipt of this report, AMRPA immediately began a fact-finding operation to analyze and dissect the report.

AMRPA Magazine / February 2019 23

Readers will find below an executive summary of the response from AMRPA, AAPM&R and FAH. A link to the full report can be found on the AMRPA website at www.amrpa.org/OIGResponse.

these findings to nearly one-half million other claims. The specifics of individual patients are unique; therefore, extrapolating findings from a small number of IRF cases to a broader universe of patients is inappropriate.

Executive Summary AMRPA, AAPM&R, and FAH Response to OIG Report on Inpatient Rehabilitation Facilities (IRFs)

OIG second-guessed physician judgment without necessary expertise: Medicare’s coverage regulations rely heavily on the decision-making skills of highly-trained rehabilitation physicians who utilize years of clinical experience and consider patientspecific factors to determine the appropriateness for an IRF admission. By ignoring physician expertise, the OIG contractor conducting the audit second-guessed physician decisions based on paper records alone. The auditor also had the benefit of information gathered during the patient’s stay, which would not be available to the treating physician at the time of admission. OIG has not revealed the qualifications of its reviewers; however, based on the information available to us, we suspect the reviewers lack the requisite experience and training to conduct these audits. We believe that OIG utilized personnel without experience in medical rehabilitation or proper understanding of the intricacies of IRF care and who are not qualified to overrule the judgment of treating physicians. In addition, the claims evaluated by OIG auditors were not subject to appeal and were not released to external stakeholders for review.

The American Medical Rehabilitation Providers Association (AMRPA), the American Academy of Physical Medicine and Rehabilitation (AAPM&R), and the Federation of American Hospitals (FAH) have strong objections to the findings and conclusions of the Department of Health and Human Services’ Office of Inspector General’s (OIG’s) recent report on inpatient rehabilitation hospitals and units. IRFs play a vital role in rehabilitation care. Every year, hundreds of thousands of Medicare beneficiaries benefit immensely from IRF stays after serious injuries or illness. The unique combination of intense rehabilitation and close medical supervision offered at IRFs enables patients to return to their lives following a serious medical event. Outcomes for most patients in IRFs are significantly better than for those served in lower-intensity levels of care. IRF patients return home earlier, remain home longer, and are less likely to be readmitted to the hospital. Most importantly, IRF patients live longer than similar patients treated in other settings. The evidence is clear that IRFs play an essential role that cannot be replicated in other settings of care. The OIG’s conclusion is unreliable and the result of flawed methodology: The OIG arrived at a flawed conclusion that 84 percent of IRF services in 2013 were not medically necessary. OIG’s supposed error rate is nearly five times higher than the error rate for 2013 found by the Centers for Medicare and Medicaid Services’ (CMS’) IRF auditor. This vast discrepancy was not explained or even acknowledged by the OIG and shows that OIG’s methods were flawed. This report examined just 220 out of 442,259 IRF claims from 2013 (less than 0.05 percent) and then extrapolated

24 AMRPA Magazine / February 2019

Regulatory burdens such as additional audits and prior authorization will jeopardize access to high-quality and lifeimproving medically necessary care: IRFs are currently audited extensively and frequently by different types of contractors—more than any other Part A provider. Contrary to recommendations by OIG, an increase in the number of audits conducted by Medicare contractors would force IRFs to redirect valuable resources from patient care. Similarly, prior authorization would delay and deny medically necessary IRF care to patients. Indeed, the OIG recently issued a report criticizing Medicare Advantage Organizations for using prior authorization to deny medically necessary care. CMS should not repeat that error to the detriment of patients who need IRF care.

2019 AMRPA Schedule of Events CONFERENCE DATES 2019 Spring Conference in Washington, DC March 10-11, 2019: Medical Directors Symposium March 11-12, 2019: Leadership Forum & Congressional Fly-In 2019 Fall Educational Conference & Expo in San Diego, California Sunday, October 13, 2019: IRF Boot Camp October 14-16, 2019: Fall Conference & Expo AMRPA MEMBERS ONLY CALLS Wednesday, February 20 at 1:00 p.m. ET Wednesday, April 17 at 1:00 p.m. ET Wednesday, June 19 at 1:00 p.m. ET Wednesday, August 21 at 1:00 p.m. ET Wednesday, October 23 at 1:00 p.m. ET Wednesday, December 18 at 1:00 p.m. ET AMRPA WEBINARS Wednesday, February 13: Understanding Your Position for FY 2020 and the New CMGs Look out for additional AMRPA webinars in the next issue! eRehabData® WEBINARS: AVAILABLE TO eRehabData® SUBSCRIBERS ONLY Tuesday, February 5: Review of 60% Rule Compliance Tuesday, March 12: Improving Discharge to Community Rates Tuesday, April 2: Nursing and Therapy Documentation Tips Tuesday, May 7: Physician Documentation Tuesday, June 4: Managing Outcomes with eRehabData

Please visit www.amrpa.org for registration information.

AMRPA Magazine / February 2019 25

Study Examines the Association of Medicaid Expansion with Access to Rehabilitative Care

Highlight: »»

Adults with trauma injuries in states that expanded Medicaid under the ACA experienced higher insurance coverage and discharge to rehabilitation post-acute care.

Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. The Patient Protection and Affordable Care Act (ACA) was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

// Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured.

A recent study in JAMA Surgery assessed the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the ACA. The study included adult trauma patients aged 19 to 64 in five Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey and New Mexico) and four nonexpansion (Florida, Nebraska, North Carolina and Texas) states. The main outcomes and measures were changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue and length of stay), and discharge to rehabilitation. Results A total of 283,878 patients from Medicaid expansion states and 285, 851 patients from non-expansion states were included (mean age [SD], 41.9 [14.1] years; 206, 698 [36.3 percent] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95 percent CI, 14.1-13.3; baseline: 22.7 percent) after Medicaid expansion compared with non-expansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95 percent CI, 7.0-7.8; baseline: 14.7 percent) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase

26 AMRPA Magazine / February 2019

in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-Midnight (8.4 percentage points) and 60 percent (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring post-acute care (e.g., pelvic fracture). It mitigated race/ethnicity-, age- and sexbased disparities in which patients use rehabilitation. This difference-in-difference analysis found that adults with injuries in expansion states experienced an absolute 13.7 percentage point decline in the percentage of patients who are uninsured after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation that persisted across inpatient rehabilitation facilities, home health agencies, and skilled nursing facilities.

Conclusions The authors concluded that expanded access to rehabilitation services due to Medicaid expansion under the ACA resulted in significant increases in insurance coverage and discharge to rehabilitation among adult trauma patients. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60,000 additional adult trauma patients nationally in expansion states. For the abstract, see Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients, JAMA Surgery, January 2, 2019.

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 / February 2019 27

Higher Nurse Staffing Levels Linked with Reduced Length of Stay, Adverse Events and Mortality

Highlights: »»

Higher levels of temporary staffing were associated with increased mortality.

»»

Adverse events and length of stay were reduced with higher RN staffing.

Although low nurse staffing levels are associated with adverse patient outcomes from hospital care, the causal relationship is still unclear. Limited capacity to observe patients has been offered as a causal mechanism according to Health Services and Delivery Research. The authors sought to determine if adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether missed vital signs observations mediate any relationship. The study included 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015. The main outcomes were death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health care assistant (HCA) staffing levels and outcomes, controlling forward and patient factors.

// As defined by the Medicare measure, a patient is successfully discharged to the community if they are discharged to self-care or home health and remain there without experiencing an unplanned rehospitalization or die within the following 31 days.

Results Over the first five days of stay, each additional hour of RN care was associated with a 3 percent reduction in the hazard of death [hazard ratio (HR) 0.97, 95 percent confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased

28 AMRPA Magazine / February 2019

hazard of death (HR 1.04, 95 percent CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16 percent of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95 percent CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RNâ&#x20AC;&#x2030;+â&#x20AC;&#x2030;HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not.

Conclusion The authors concluded that higher nursing staffing levels are associated with lower mortality, and there may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety. However, the researchers state that more evidence is required to validate approaches to setting staffing levels and the implications of findings about both costs and temporary staffing need further exploration. For the study, see Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study, Health Services and Delivery Research, November 2018.

The study limitations included a single site and evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff and economic analysis did not consider quality or length of life.

AMRPA Magazine / February 2019 29

Accountable Care Organizations Can Improve Results by Focusing on High-risk Patients, Commonwealth Fund Reports

Highlights: »»

High-need, high-cost patients make up only 5 percent of the population but account for 50 percent of health care spending.

»»

The report suggests a hybrid model that uses qualitative data to identify patients for care management as the best approach.

New payment and care delivery models such as accountable care organizations (ACOs) have prompted health care delivery systems to better meet the requirements of their high-need, highcost (HNHC) patients. Accountable care organizations that engage primary care physicians are more suitable to get buy-in on programs that target these patients, according to a report by the Commonwealth Fund.

// HNHC patients make up only 5 percent of the population but account for 50 percent of health care spending.

HNHC patients make up only 5 percent of the population but account for 50 percent of health care spending. ACOs and other value-based payment models are looking to improve care and quality while reducing costs of the highest-cost patients. The study authors examined how new payment and care delivery models such as ACOs are meeting the needs of these patients. The authors studied Medicare ACOs and a few Medicaid ACOs operating under Centers for Medicare and Medicaid Services (CMS) authority that had been in place for at least three years, or those that had a long history of risk contracting before becoming an ACO. The researchers conducted telephone interviews with leaders from 18 ACOs and 10 national experts in risk stratification and segmentation. They found that algorithms based only on claims data don't offer adequate clinical, behavioral health or social need information. Also, previous research has shown that patient health risk assessments or physicians choosing patients for care management aren't effective. The authors found that ACOs use a range of approaches to segment their HNHC patients and although there was no consistent set of subgroups, there were some common ones. Respondents noted that when primary care clinicians were engaged in refining segmentation approaches, there was an increase in both the clinical relevance of the results as well as the willingness of frontline providers to use them. Population

30 AMRPA Magazine / February 2019

segmentation results informed ACOs’ understanding of program needs, for example, by helping them better understand what skill sets and staff were needed to deliver enhanced care management. They concluded that findings on how mature ACOs are segmenting their HNHC population can improve the future development of more systematic approaches.

For the complete report, see How Accountable Care Organizations Use Population Segmentation to Care for High-Need, High-Cost Patients, Commonwealth Fund, January 3, 2019.

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AMRPA: Working Together Access to Medical Rehabilitation AMRPA: Working Together to To Preserve Preserve Access To Medical Rehabilitation Maggie · VP ofMember Membership Services · 347-573-3732 · mramirez@amrpa.org JuliaRamirez Scott, AMRPA Services Coordinator, 202-207-1110, jscott@amrpa.org

AMRPA Magazine / February 2019 31

GAO Issues Report on Medicare Payments for Long-term Care Hospitals that Specialize in Spinal Cord Treatment

Highlights: »»

Similarities and differences may exist between the two qualifying hospitals examined and other facilities that treat Medicare patients with spinal cord and brain injuries.

»»

Different Medicare payment requirements that apply to LTCHs and IRFs affect the types of services they provide and the patients they treat.

The Government Accountability Office (GAO) issued a report on its review of Medicare payments to long-term care hospitals (LTCHs) that specialize in spinal cord treatment. Spinal cord injuries (SCIs) may result in secondary complications that often lead to decreased functional independence and quality of life. After an injury or illness, Medicare patients who need long-term care are able to receive care from different types of facilities.

// Medicare’s LTCH payments are typically higher than payments to other post-acute care (PAC) facilities because long-term acute care can take more resources, such as specialized equipment and staff.

Background Medicare’s LTCH payments are typically higher than payments to other postacute care (PAC) facilities because long-term acute care can take more resources, such as specialized equipment and staff. Traditionally, LTCHs are paid under Medicare’s LTCH prospective payment system (PPS) at the LTCH PPS standard federal payment rate. However, the Pathway for SGR Reform Act of 2013 introduced a site-neutral payment policy for LTCHs, which changed Medicare’s payment for services that could be provided in other less costly settings. The policy began in fiscal year (FY) 2016.

As a result, the LTCH PPS is now a two-tiered payment system under which certain LTCH discharges continue to be paid at the standard rate, while other discharges are paid at a generally lower “site-neutral” rate, equivalent to the Inpatient Hospital PPS (IPPS) rate. The site-neutral policy is being phased into the LTCH PPS over five years, with certain exceptions. In addition, statute provides that, by fiscal year 2021, LTCHs will no longer receive the standard rate if they fail to meet certain requirements. This has raised access concerns as some LTCHs may no longer provide care to certain patients if they are paid at the site-neutral rate. The 21st Century Cures Act provided a temporary exception to the site-neutral policy for certain LTCHs that provide spinal cord specialty treatment during FYs 2018 and

32 AMRPA Magazine / February 2019

2019. To qualify for this exception, LTCHs must meet three criteria and two LTCHs did so—Craig Hospital in Englewood, Colorado, and Shepherd Center in Atlanta, Georgia. Under current law, the LTCH PPS two-tiered payment system will apply to these hospitals after the exception expires, in fiscal year 2020 and beyond. For this report, the GAO examined: 1. The health care needs of Medicare beneficiaries who receive services from the two qualifying hospitals; 2. How Medicare LTCH payment polices could affect the two qualifying hospitals; and 3. How the two qualifying hospitals compare with other LTCHs and other facilities that may treat Medicare patients with similar conditions. GAO analyzed Medicare claims data for FYs 2013 through 2016 and other data for the two qualifying hospitals and other facilities that treated patients with SCIs. GAO also interviewed HHS officials and stakeholders from the qualifying hospitals, other facilities that treat spinal cord patients, specialty associations, and others. GAO conducted this performance audit from October 2017 through December 2018. GAO’s Findings Most Medicare Beneficiaries who Receive Services at the Two Qualifying LTCHs Need Specialized Follow-Up Care to Manage Long-term Effects of Catastrophic Injury GAO found that most Medicare beneficiaries at the two qualifying hospitals need specialized services to manage the chronic, long-term effects of a catastrophic spinal cord or brain injury. Most of these patients are younger than 65 and were ineligible for Medicare at the time of their initial injury, according to officials from the qualifying hospitals. These patients typically become eligible for Medicare two years or more after their initial injury due to disability. These patients typically need care to manage comorbidities or the associated long-term complications of their injury. Officials from both qualifying hospitals noted their Medicare beneficiaries who have a spinal cord or brain injury also frequently seek care after initial injury to address secondary complications resulting from their injury, including urinary tract infections, respiratory problems and pressure ulcers. While the hospitals primarily treated traumatic spinal cord or brain injuries, GAO found that their Medicare populations differed from each other during the period from 2013 to 2016.

Medicare Policies May Have Modest Effects on Payments to the Two Qualifying Hospitals Depending on the Types of Patients Treated and Other Factor GAO's simulations of Medicare payments to these two hospitals using claims data from these two baseline years showed the potential effects of payment policies. LTCHs are paid under a two-tiered system for care provided to

beneficiaries: they receive the LTCH standard federal payment rate for certain patients discharged from the LTCH, and a site-neutral rate for all other discharges. Under the temporary exception, Craig Hospital and Shepherd Center receive the standard rate for all discharges during fiscal years 2018 and 2019. Assuming their types of discharges remain the same as in fiscal years 2013 and 2016, GAO's simulations of Medicare payments in the baseline years indicated that: Most of the discharges examined would not qualify for the standard rate, if the exception did not apply. Medicare payments would generally decrease under FY 2020 payment policy, once the exception expires. However, the actual effects of Medicare's payment policies on these two hospitals could vary based on factors, including the severity of patient conditions (e.g., Medicare payment is typically higher for more severe injuries) and whether hospitals' discharges meet criteria for the standard rate.

Similarities and Differences May Exist Between the Two Qualifying Hospitals and Other Facilities that Treat Medicare Patients with Spinal Cord and Brain Injuries Patients with spinal cord and brain injuries may receive care in other LTCHs, but GAO found that most Medicare beneficiaries at these other LTCHs are treated for conditions other than spinal cord and brain injuries. Certain inpatient rehabilitation hospitals or units (IRH/Us) also provide post-acute rehabilitation services to patients with spinal cord and brain injuries. While data limitations make a direct comparison between these facilities and the two qualifying hospitals difficult, GAO identified some similarities and differences. For example, officials from some IRH/Us interviewed reported providing several of the same programs and services as the two qualifying hospitals to medically complex patients, but the availability of services and complexity of patients varied. Among other reasons, the different Medicare payment requirements that apply to LTCHs and IRFs affect the types of services they provide and the patients they treat. Differences in payment systems and data limitations make it difficult to directly compare the attributes of Medicare beneficiaries discharged from the two qualifying LTCHs and IRH/Us, including the costs of care they receive. Medicare uses separate payment systems to pay LTCHs and IRH/ Us, for care provided to beneficiaries. According to CMS officials, because the payment groups and assignments to those groups are different, it is difficult to directly compare LTCH patients, classified in diagnosis groups, with IRH/Us patients, classified in case-mix groups. For the complete report, see Medicare: Payments for Certain Long-Term Care Hospitals that Specialize in Spinal Cord Treatment, GAO, December 13, 2018.

AMRPA Magazine / February 2019 33

OIG Issues Report on Adverse Events in Long-term Care Hospitals

Highlights: »»

According to the OIG, approximately 46 percent of Medicare beneficiaries experienced an adverse or temporary harm event in LTCHs in 2014.

»»

Compared to acute care hospitals, LTCHs and other PAC providers have fewer adverse events and temporary harm events per 1,000 patient days.

In a series of reports from 2008–2016, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has focused on adverse events and temporary harm events that are common and costly to the Medicare program. Its recent report builds upon previous work in post-acute-care (PAC) settings, focusing on long-term acute care hospitals (LTCHs). The OIG conducted this report based on Medicare data from 2014 in order to: Estimate the incidence of adverse events and temporary harm events for Medicare patients admitted to LTCHs;

// The OIG found that nearly half of patients experienced adverse events or temporary harm events and a significant proportion of these events were considered serious...

Assess the extent to which adverse events and temporary harm events were preventable and to identify factors contributing to these events. The OIG found that nearly half of patients experienced adverse events or temporary harm events and a significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of lifesaving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Health care Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) specifically address long-term acute care hospitals. With approximately 400 providers in the Medicare Program, LTCHs are less common than other types of PAC providers and account for about 6 percent of Medicare expenditures for PAC. To receive Medicare designation as an LTCH, a hospital must meet all the requirements for short-term acute-care hospitals and have an average length of stay (ALOS) greater than 25 days. In fiscal year 2015, Medicare spent $5.3 billion on LTCH care, with an average stay costing Medicare over $40,000. In a series of reports from 2008 to 2016, OIG found 34 AMRPA Magazine / February 2019

that adverse events and temporary harm events are common, endanger patient health, and are costly to the Medicare program. In a 2010 study, OIG found that 27 percent of hospitalized Medicare beneficiaries experienced such events, costing Medicare approximately $4.4 billion a year. OIG then expanded on this work by examining PAC settings, finding that 33 percent of Medicare beneficiaries in skilled nursing facilities (SNFs) and 29 percent of Medicare beneficiaries in rehabilitation hospitals experienced harm. Methods OIG reviewed medical records for 587 Medicare beneficiaries admitted to LTCHs in March 2014 to establish a national incidence rate of adverse events and temporary harm events. The review was conducted in two stages. In the first stage, nurses screened records for possible harm events. In the second stage, OIG’s physician reviewers conducted a comprehensive review of the records flagged as containing possible harm events. The physicians identified the harm events, determined the level of harm, whether the events were preventable, and the factors that contributed to the events. Findings The OIG found that: 21 percent of Medicare patients had adverse events during their LTCH stays. One in five Medicare patients (21 percent) experienced adverse events during their stays in LTCHs. OIG estimates that a total of 2,388 Medicare patients experienced at least one adverse event during the study period. Seventeen percent of these patients experienced more than one adverse event. These events resulted in harm within the four most serious categories (F-I) on the OIG’s modified National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index and represent both preventable and not preventable events. The majority (53 percent) of adverse events experienced by patients caused F level harm (meaning it prolonged the LTCH stay, became the primary reason for treatment, or required transfer to another facility.) More than 40 percent resulted in the need for lifesaving intervention (21 percent) or contributed to death (20 percent), and the final 6 percent of events contributed to permanent harm as shown in Exhibit 2.

An additional 25 percent of Medicare patients had temporary harm events during their LTCH stays. In addition to the 21 percent of patients who experienced adverse events, 25 percent of Medicare patients in LTCHs experienced temporary harm events. These events were classified as E-level harm on the NCC MERP Index, which is defined as harm events that required intervention but did not prolong the LTCH stay, necessitate higher levels of care, require life-sustaining intervention, or result in lasting harm. OIG estimates that 2,770 LTCH patients experienced at least one temporary harm event during the study month and of these patients 1,108 had more than one unrelated event. Additionally, 39 percent of patients who experienced an adverse event also had temporary harm events during their stays. As with adverse events, temporary harm events represented a wide array of conditions from the three clinical categories as shown in Exhibit 4.

Adverse events were most often related to health careacquired infections (45 percent) with 31 percent related to the use of medication, and 23 percent related to general patient care. Exhibit 3 shows the types of adverse events within each category.

AMRPA Magazine / February 2019 35

Longer stays in LTCHs present more opportunities for adverse events and temporary harm events. With 46 percent of Medicare patients experiencing either adverse or temporary harm events, the incidence of harm in LTCHs is higher than the OIG identified in other health care settings, including acute-care hospitals (27 percent), SNFs (33 percent), and rehabilitation hospitals (29 percent). However, in comparing harm rates across settings, the OIG states that it is important to note that patients in LTCHs have longer lengths of stay on average than patients in acute-care hospitals, SNFs or rehabilitation hospitals. These longer lengths of stay result in more medical interventions over time and, therefore, more opportunities for harm to occur. The ALOS for LTCH patients in the OIG’s sample was 26.3 days. In comparison, ALOS for samples in similar OIG studies were 5.2 days in acute care hospitals, 15.5 days in SNFs and 12.7 days in rehabilitation hospitals. Using a different metric to measure the frequency of events, the rate of events in LTCHs looks more comparable to other PAC settings (SNFs and rehabilitation hospitals) and lower than acute-care hospitals. Incidence density is a metric often used by health care facilities to track performance, and is defined as the number of events per 1,000 patient days. OIG found that the incidence density in LTCHs was 38 adverse events and temporary harm events per 1,000 patient days. Prior OIG reports found that patients admitted to acutecare hospitals experienced a significantly higher number of events per day, with 69 events per 1,000 patient days and that Medicare patients in rehabilitation hospitals and SNFs experienced fewer events per 1,000 patient days (29 events in rehabilitation hospitals and 24 events in SNFs) than LTCHs (38 events) as shown in Exhibit 5.

suited to the patients and less likely to result in harm events. More than half of adverse events and temporary harm events were preventable. The incidence rates for adverse events and temporary harm events include both preventable and non-preventable events. OIG’s physician reviewers also assessed each event to determine whether it could have been prevented. Using the documentation in the medical records, they determined that more than half of adverse events and temporary harm events (54 percent) were clearly or likely preventable and that most of the remaining events (45 percent) were clearly or likely not preventable. Physicians were unable to make a determination for the remaining one percent of events because of incomplete documentation or complexities in the patients’ conditions. If it were to include only preventable events in the incidence rates, the percent of Medicare patient in LTCHs that experienced preventable adverse events would be 14 percent (rather than 21 percent) and the percent of patients that experienced preventable temporary harm events would also be 14 percent (rather than 25 percent). Adverse events were more likely to be preventable than temporary harm events (62 percent of adverse events were preventable versus 50 percent of temporary harm events). OIG’s Recommendations The OIG recommends that AHRQ and CMS collaborate to create and disseminate a list of potential adverse events in LTCHs, provide facility staff with the information to correct problems and reduce harm, and seek opportunities within their existing programs to raise awareness of the types of harm in LTCHs. Many events were the result of substandard care or medical errors and Medicare patients in LTCHs were particularly susceptible to some types of harm, according to the OIG. In response to OIG’s recommendations in earlier reports about adverse events in acute-care hospitals, SNFs and rehabilitation hospitals, AHRQ and CMS collaborated to create lists of potentially reportable adverse events. The lists are in various stages of review and use, but have been used by the agencies and facilities to inform providers, measure performance and/ or to promote safety. The OIG states that the list could also be used as a resource for educating LTCH staff about patient safety and developing ways to measure facility performance and that AHRQ and CMS should expand these efforts to provide information about adverse events and temporary harm events in LTCHs.

Compared with acute-care hospitals, the lower number of events per day in LTCHs may be attributable to differences in the patient populations and the care provided. Acutecare hospitals treat sudden and often urgent illnesses and injuries and, therefore, are more likely to perform surgical and other procedures that can put patients at risk. Although LTCHs treat medically complex and high acuity patients, clinicians and staff may have more opportunity to become familiar with their patients’ conditions, owing to their longer stays, which may result in care that is better36 AMRPA Magazine / February 2019

CMS and AHRQ concurred with OIGs recommendations. Prior OIG Reports on Adverse Events OIG released 12 reports on adverse events in hospitals from 2008–2016, including reports about the incidence of adverse events, methods for identifying adverse events, state reporting systems, and public disclosure of event information. All reports are available on the OIG website at oig.hhs.gov/newsroom/ spotlight/2012/adverse.asp.

High-Cost Medicare Beneficiaries Spend More on Outpatient Care and Medications

Highlights: »»

Study recommends developing targeted interventions to help reduce overall Medicare spending for high-cost Medicare beneficiaries.

A small portion of Medicare patients— 10 percent — account for more than half the Medicare spending in any given year, but less is known about how many of these patients continue to incur high costs over time. Using three years of Medicare claims data (2012–2014), researchers sought to determine the share of patients with persistently high costs, as well as the key traits that differentiate them from those who incur high costs in only one or two years — or never. The Commonwealth Fund-supported study offers policymakers ideas for targeted interventions to lower federal health care spending.

// More than one-quarter (28 percent) of patients who had high costs in 2012 remained persistently highcost over the subsequent two years.

The study found that: More than one-quarter (28 percent) of patients who had high costs in 2012 remained persistently high-cost over the subsequent two years. The remaining 72 percent were transiently high-cost, meaning they had high costs for one or two years. Persistently high-cost patients were younger (66.4 years) than either the transiently high-cost (73.3 years) or never high-cost (70.5 years) patients. They were also more likely to be members of racial and ethnic minorities, dually eligible for Medicaid in addition to Medicare, and qualify for Medicare because of end-stage renal disease. On average, persistently high-cost patients spent $64,434 in the first year, compared with $45,560 for the transiently high-cost and $4,538 for the never highcost patients. Persistently high-cost patients spent more in all categories of spending. Notably, they spent more than four times as much as transiently high-cost patients did in outpatient settings ($16,148 v. $4,020) and on drugs ($15,467 v. $3,841).

AMRPA Magazine / February 2019 37

The authors recommend developing targeted interventions on those two areas that could help reduce overall Medicare spending.

Average per person per year total spending for Medicare beneficiaries, by high-cost status, 2012–14

See the Commonwealth Fund’s website to read the statement, “More Than One-Quarter of High-Cost Medicare Patients Have Persistent High Costs Over Three Years”, January 7, . 2019.

Data: Authors’ analysis of Medicare claims data for 2012–14. Source: José F. Figueroa, Xiner Zhou, and Ashish K. Jha., “Characteristics and Spending Patterns of Persistently High-Cost Medicare Patients,” Health Affairs 38, no. 1 (Jan. 2019): 107–14.

38 AMRPA Magazine / February 2019

CHCS Develops Checklist to Assist States in Adopting Value-based Payment Models for Home and CommunityBased Services Highlight: »»

Home- and community-based services spending is expected to grow by 2030 due to increasing numbers of individuals aged 65 and older, and the ongoing needs for services among high-cost HCBS users, particularly those with intellectual and developmental disabilities.

State Medicaid agencies and their contracted managed care plans are shifting away from fee-for-service (FFS) systems to value-based payment (VBP) models that tie provider payment to better outcomes. Although most Medicaid VBP models target medical care, states are beginning to explore payment reforms that encourage quality and outcomes for long-term services and supports. The Center for Health Care Strategies (CHCS) identified four issues that states may want to explore as they develop and adopt VBP models for home- and community-based services (HCBS) within managed long-term services and supports (LTSS) programs. The issues include: Assessing available support from the state policy environment;

// Although most Medicaid VBP models target medical care, states are beginning to explore payment reforms that encourage quality and outcomes for long-term services and supports.

Selecting the right performance measures to reward HCBS providers; Selecting payment models that create the right financial incentives for improved value; and Addressing operational issues faced by plans and providers. The checklist also suggests opportunities throughout a program, from initial design to implementation through evaluation and ways for ongoing engagement of key stakeholders (e.g., managed care plans, providers, and beneficiaries and their families).

AMRPA Magazine / February 2019 39

The accompanying report from CHCS states that: In 2016, LTSS comprised 30 percent ($167 billion) of all federal and state Medicaid spending with 57 percent of that devoted to HCBS, increasing state interest in developing new payment models for HCBS. HCBS spending will grow, due to an anticipated 50 percent increase in individuals age 65 and older by 2030, and the ongoing needs for services among high-cost HCBS users, particularly those with intellectual and developmental disabilities. HCBS quality and outcomes depend on the supply and skills of direct care workers, but there are challenges with worker recruitment, retention, and career development opportunities that these models could help address. Many state Medicaid programs seek to improve the quality and cost-effectiveness of LTSS by transforming how they pay providers for these services. State Medicaid agencies, and their contracted managed care plans, are shifting away from FFS systems that reward providers for delivering more services to VBP) models that tie payment to better outcomes. Although most Medicaid VBP models target medical care, states are beginning to explore payment reforms that encourage quality and outcomes for LTSS. As of 2017, nearly half of all states contracted with managed care plans to cover LTSS, including HCBS.

40 AMRPA Magazine / February 2019

Before beginning the design of a VBP model, a state should clearly articulate its overall policy and program goals. VBP is a tool to help achieve goals, not a goal in and of itself. Desired goals may be broad (e.g., reducing potentially avoidable hospitalizations statewide) or targeted (e.g., increasing access to employment services or improving member satisfaction with assisted living facilities). Once its goals are articulated, a state can evaluate: (1) whether VBP is the right strategy to achieve them; and, if so (2) how it could direct managed care plans to use VBP arrangements with providers to support the goals. The checklist was adapted from the guide, Achieving Value in Medicaid Home- and Community-Based Care: Options and Considerations for Managed Long-Term Services and Supports Programs, which shares considerations for selecting and implementing quality metrics and payment models, as well as common challenges that states may face in adopting these models. It includes lessons from five states — Minnesota, New York, Tennessee, Texas, and Virginia — that participated in Advancing Value in Medicaid Managed LTSS, an initiative led by the Center for Health Care Strategies. For the report, see Value-Based Payment in Medicaid Managed Long-Term Services and Supports: A Checklist for State, Center for Health Care Strategies and Mathematica, Technical Assistance Tool, December 2018.

Study Examines PROMIS Use During Outpatient Orthopedic Visits

Highlight: ÂťÂť

PROMIS use was found to have positive impact on patient experience.

A recent study sought to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) use as part of routine orthopedic clinical care is associated with improved patient experience, as measured by the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) survey. PROMIS is a set of patientreported measures that evaluates and monitors physical, mental and social health in patients. The results were published in Musculoskeletal Care. The study reviewed all patient visits to an orthopedic surgery clinic at a single academic medical center between February 2015 and September 2016. Accounting for known patient factors that have an impact on clinic visit satisfaction, CGCAHPS scores were compared between patients who had PROMIS used as part of their routine care and those who had not had PROMIS used as part of their routine care.

// When PROMIS was used, patients were significantly more likely to feel that the provider had spent enough time with them, to recommend this provider office to another patient and to rate the provider significantly higher on a scale from 0 to 10.

Of 8,607 patients included in the study, surgeons elected not to use PROMIS in 8,422 patient encounters, leaving 185 patient visits in which PROMIS was actively used. When PROMIS was used, patients were significantly more likely to feel that the provider had spent enough time with them, to recommend this provider office to another patient and to rate the provider significantly higher on a scale from 0 to 10. Although not significant, a trend was found between use of PROMIS and whether a patient felt that a provider explained health information in way that the patient understood. The study found that PROMIS use in an orthopedic clinic visit can have a positive impact on the patient experience, which is a focus of many health care stakeholders and currently a part of a number of various alternative payment models. See the study, Patient-reported outcomes use during orthopedic surgery clinic visits improves the patient experience, in Musculoskeletal Care, January 7, 2019.

AMRPA Magazine / February 2019 41

Latest Research Findings

Study Examines the Impact of Exercise-based Cardiac Rehabilitation in People with Atrial Fibrillation A recent study published in Open Heart examined the impact of exercise-based cardiac rehabilitation (CR) targeted at patients with atrial fibrillation (AF). The authors conducted searches of PubMED, EMBASE and the Cochrane Library of Controlled Trials. Randomized and non-randomized controlled trials were included if they compared the effects of an exercise-based CR intervention to a no exercise or usual care control group, and meta-analyses of outcomes were conducted where appropriate. The nine randomized trials included 959 patients (483 exercisebased CR vs 476 controls) with various types of AF. Compared with control, the study did not find a difference in all-cause mortality (risk ratio (RR) 1.08, 95 percent CI 0.77 to 1.53, p=0.64) following exercise-based CR. However, there were improvements in healthrelated quality of life (mean SF-36 mental component score (MCS): 4.00, 95 percent CI 0.26 to 7.74; p=0.04 and mean SF-36 physical component score: 1.82, 95 percent CI 0.06 to 3.59; p=0.04) and exercise capacity (mean peak VO2: 1.59 ml/kg/min, 95 percent CI 0.11 to 3.08; p=0.04; mean 6 min walk test: 46.9 m, 95 percent CI 26.4 to 67.4; p<0.001) with exercise-based CR. Improvements were also seen in AF symptom burden and markers of cardiac function. Exercise capacity, cardiac function, patientsâ&#x20AC;&#x2122; symptom burden and health-related quality of life were improved with exercise-based CR in the short term (up to six months) targeted at patients with AF. The authors state that additional high-quality multicenter randomized trials are needed to clarify the impact of exercisebased CR on key patient and health system outcomes (including 42 AMRPA Magazine / February 2019

health-related quality of life, mortality, hospitalization and costs) and how these effects may vary across AF subtypes. To read the complete study, see Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials, Open Heart, December 20, 2018.

Three-Dimensional Balance Training Using Visual Feedback May Be More Effective Than Conventional Training in Patients with Subacute Stroke A recent study aimed to explore the effects of three-dimensional balance training using visual feedback on balance and walking ability in subacute stroke patients. Trunk-activating exercises for balance are important because trunk weakness is relevant to the functional performance of individuals with stroke. Twenty-four participants with subacute stroke were randomly assigned to the experimental or control group. Each group underwent 20 sessions (30 minutes/day, five days/week for four weeks). Patients were assessed using the Berg balance scale, gait parameters (gait speed, cadence, step length, and double-limb support period) using GAITRite, and activity-specific balance confidence scores, before and after the intervention. The three-dimensional balance training using visual feedback presented greater changes in the Berg balance scale, gait speed, cadence, step length, double-limb support period, and activityspecific balance confidence compared with the control group. Statistical analyses showed significant differences in Berg balance scale (P = .012; 95 percent CI, 2.585-6.415), gait speed (P = .001; 95 percent CI, .079-.155), cadence (P = .001; 95 percent CI, 1.6224.392), step length (P = .003; 95 percent CI, 1.864-3.908), doublelimb support period (P = .003; 95 percent CI, -3.259 to -0.761) and activity-specific confidence (P = .008; 95 percent CI, 6.964-14.036) between groups. The authors concluded that three-dimensional balance training using visual feedback may be more effective than conventional

training in improving balance, walking ability and activity-specific balance confidence in patients with subacute stroke. For the study, see Three-Dimensional Balance Training Using Visual Feedback on Balance and Walking Ability in Subacute Stroke Patients: A Single-Blinded Randomized Controlled Pilot Trial, in the Journal of Stroke and Cardiovascular Diseases, January 3, 2019.

Risk Adjustment is Necessary in Value-based Payment Models for Arthroplasty for Oncology Patients Value-based payment models such as bundled payments have been introduced to reduce costs following total hip arthroplasty (THA). However, concerns exist about access to care for patients who utilize more resources. Findings published in the Journal of Arthroplasty compared resource utilization and outcomes of patients undergoing THA for malignancy with those undergoing THA for fracture or osteoarthritis.

The authors used the American College of Surgeons National Surgical Quality Improvement Program database to identify all hip arthroplasties performed from 2013 to 2016 for a primary diagnosis of malignancy (n = 296), osteoarthritis (n = 96,480), and fracture (n = 13,406). The rates of readmissions, reoperations, comorbidities, mortality and surgical characteristics were compared between the three cohorts. To control for confounding variables, a multivariate analysis was performed to identify independent risk factors for resource utilization and outcomes following THA.

AMRPA Magazine / February 2019 43

Patients undergoing THA for malignancy had a longer mean operative time (155.7 vs 82.9 vs 91.0 minutes, P < .001), longer length of stay (9.0 vs 7.2 vs 2.6 days, P < .001), and were more likely to be discharged to a rehabilitation facility (42.1 percent vs 61.8 percent vs 20.2 percent, P < .001) than patients with fracture or osteoarthritis. When controlling for demographics and comorbidities, patients undergoing THA for malignancy had a higher rate of readmission (adjusted odds ratio 3.39, P < .001) and reoperation (adjusted odds ratio 3.71, P < .001). The authors found that patients undergoing THA for malignancy use more resources in an episode-of-care and have worse outcomes. Risk adjustment is necessary for oncology patients in order to prevent access to care problems for these high-risk patients. See the study, Risk Adjustment Is Necessary in Value-based Payment Models for Arthroplasty for Oncology Patients, in the Journal of Arthroplasty, December 16, 2018.

Prescription Opioid Behaviors Among Adults With and Without Disabilities Prescription opioid use among people with disabilities has not been well characterized, according to a study published in the Disability and Health Journal. Researchers from the University of New Hampshire, College of Health and Human Services’ Institute on Disability examined prescription opioid use, misuse, use disorder and other prescription opioid use among persons with and without disabilities. Study methods consisted of a stratified analysis of prescription opioid use, misuse and use disorders; primary reason and primary source for last prescription opioid misuse; receipt of

prescription opioid treatment; and disability status among civilian, noninstitutionalized adults (ages 18+). The data was taken from the 2015–2016 National Survey on Drug Use and Health. The report found that adults with disabilities were significantly more likely than adults without disabilities to experience past year prescription opioid use (52.3 percent for those with disabilities compared to 32.8 percent of those without), misuse (4.4 percent compared to 3.4 percent) and use disorders (1.5 percent compared to 0.5 percent). People with disabilities were significantly more likely to misuse opioids for pain (Risk Ratio = 1.5, p < 0.001) and to receive opioids from a health care provider (Risk Ratio = 2.0, p < 0.001). Among people with opioid use disorder, people with disabilities were less likely to receive treatment for prescription opioid use (Risk Ratio = 0.6, p = 0.067). The authors concluded that in the United States, a substantial population with disabilities using and misusing prescription opioids exists that has not been well characterized. Persons with disabilities experience disparities in reasons and sources for last opioid misuse. Health care and substance abuse prevention, intervention and treatment providers must collaborate to address the needs of this population. To read the abstract, see Prescription opioid behaviors among adults with and without disabilities – United States, 2015–2016, in the Disability and Health Journal, December 15, 2018.

44 AMRPA Magazine / February 2019

AMRPA Congressional News Center The 116th Congress was sworn in on January 3, 2019. There have been some notable changes to Congressional leadership, please find these updates below. House of Representatives Democratic Leadership Speaker - Nancy Pelosi (D-CA-12) Majority Leader - Steny Hoyer (D-MD-5) Majority Whip - Jim Clyburn (D-SC-6) Assistant Speaker - Ben Ray Lujan (D-NM-3) Democratic Caucus Chairman - Hakeem Jeffries (D-NY-8) Democratic Congressional Campaign Committee Chairwoman - Cheri Bustos (D-IL-17) House of Representatives Republican Leadership Minority Leader - Kevin McCarthy (R-CA-23) Minority Whip - Steve Scalise (R-LA-1) Republican Conference Chairwoman - Liz Cheney (R-WY-At Large) National Republican Congressional Committee Chairman Tom Emmer (R-MN-6)

Senate Democratic Leadership Minority Leader – Charles Schumer (D-NY) Minority Whip – Richard Durbin (D-IL) Assistant Minority Leader – Patty Murray (D-WA) Chairwoman of Policy & Communications Committee – Debbie Stabenow (D-MI) Vice Chair of Conference – Elizabeth Warren (D-MA) Vice Chair of Conference – Mark Warner (D-VA) Chair of Steering Committee – Amy Klobuchar (D-MN) Chairman of Outreach – Bernie Sanders (I-VT) Vice Chairman of Policy & Communications Committee – Joe Manchin (D-WV) Secretary of the Conference – Tammy Baldwin (D-WI) Chairman of Campaign Committee – Chris Van Hollen (D-MD)

Senate Republican Leadership Majority Leader – Mitch McConnell (R-KY) Assistant Majority Leader – John Thune (R-SD) Conference Chairman – John Barrasso (R-WY) Vice Chairman of the Senate Republican Conference – Joni Ernst (R-IA) Republican Policy Committee Chairman – Roy Blunt (R-MO) Republican Senatorial Committee Chairman – Todd Young (R-IN)

If you haven’t done so already, AMRPA encourages its members to reach out to their newly or re-elected Congressional representatives and educate them about the value of care provided in inpatient rehabilitation hospitals and units by offering them a tour of your hospital, meeting with them at their offices, or visiting with them during town hall or community meetings. You may follow these steps to set up a meeting with your Congressional Representatives: Call the U.S. Capitol Switchboard at (202) 224-3121 and ask for your Senators’ and Representative's office or access their contact information online at www.house.gov and www.senate.gov. Ask the office for instructions regarding the preferred way to submit a request for a meeting or an invitation to tour your hospital or unit in the District/State. Congressional offices handle their District scheduling requests differently. The Washington, D.C. office may arrange for the meeting directly or may refer you to their Congressional District office to set up the visit. Once you have a meeting or tour scheduled, please inform Kendall Hussey by email (khussey@akingump.com) or call her at 202-416-5207 so we can track AMRPA’s outreach efforts. We encourage members to also check the Congressional News Center webpage for more up-to-date information: https://amrpa.org/ Advocacy-News/Congressional-Affairs/Congressional-News-Center. If you have any questions or feedback, contact Catherine Beal at cbeal@amrpa.org or (202) 860-1006.

AMRPA Magazine / February 2019 45

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

Announcing The AMRPA QRP Certification Program A New Era for Rehabilitation has Begun! Starting October 1, 2019, CMS is eliminating FIM from the IRF-PAI and introducing CMGs based on the GG-H QRP questions. AMRPA is working on key aspects of this change, from policy review and critique to helping hospitals adjust their day-to-day operations. As part of this work, AMRPA is happy to announce the AMRPA QRP Certification Program. Available in early 2019, this system will allow AMRPA member hospitals, as well as eRehabData® subscribers, to electronically test staff on their expertise of the QRP data elements in the IRF-PAI. The tests will be administered through AMRPA’s own eRehabData® system. Best of all, AMRPA member hospitals and eRehabData® subscribers will have unlimited use of this powerful resource, free of charge. Together, we can make the transition from FIM to GG-H smooth and seamless. To learn more, please visit eRehabData.com

46 AMRPA Magazine / February 2019

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AMRPA Magazine / February 2019 47

AMRPA & eRehabDataÂŽ Have Your Back

We adapt to regulatory updates to provide real time outcomes reports to inpatient rehabilitation hospitals and units.

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. 50 AMRPA Magazine / February 2019