AMRPA Magazine | February 2020 by AMRPA

February 2020 â&#x20AC;¢ Vol. 23, No.2

Spring Conference

& Congressional Fly-In

Watergate Hotel â&#x20AC;˘ Washington, DC

February 2020 â&#x20AC;˘ Vol. 23, No. 2

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

Table of Contents Letter from the Chair

Legislative Update

Robert Krug, MD Chair, AMRPA Board of Directors, President and CEO Mount Sinai Rehabilitation Hospital Medical Director, PM&R Service Line

CMS Requests Legal Guidance from HHS on Applying Supreme Court Decision

CMG Trends

John Ferraro, MS AMRPA Executive Director

The Next Chapter on the Unified Post-Acute Care Prospective Payment System: Summary of the November 19 CMS/RTI Technical Expect Panel

Patient Success Story: Marisa Boasa Challenging the Prognosis and Fighting for Mobility

Patricia Sullivan AMRPA Senior Editor

CMS Actuary Details 2018 National Health Expenditures

Brian McGowan Design and Layout

MedPAC Formally Votes to Recommend Payment Reductions to Congress for IRFs

AMRPA Magazine, Volume 23, Number 2

CMS Evaluation Finds Next Generation ACOs Led to Increased Spending in Performance Year Two

Kate Beller, JD AMRPA Executive Vice President for Government Relations and Policy Development Remy Kerr, MPH AMRPA Health Policy and Research Manager

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. 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, Suite 1280,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 1280, Washington, DC 20045

AMRPA Magazine / February 2020

Letter from the Chair

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

Ripple Effects 2020 marks a pivotal year for post-acute care (PAC) providers across the Medicare program. As of federal fiscal year (FY) 2020, inpatient rehabilitation hospitals and units (IRFs) transitioned to a new case-mix group payment system, and the Centers for Medicare and Medicaid Services (CMS) now pays skilled nursing facilities (SNFs) under the new PatientDriven Payment System (PDPM). Home health agencies (HHAs) also started a new payment system that is similar to SNFs (called the Patient-Driven Grouping Model, or PDGM), effective January 2020. CMS has asserted that the recent changes in the SNF and HHA payment systems are part of the overarching effort to move away from fee-for-service and toward value-based care. PDPM and PDGM are designed to reimburse based on patient characteristics and medical acuity and not the amount of therapy provided. Medicare’s revamp of these payment systems aims to correct for the perceived overuse of therapy in prior payment years, and instead enhance reimbursement for medical services – such as ventilators and respiratory care. In the immediate aftermath of the policy changes, some providers have already implemented institutional changes to adapt to the new payment incentives of PDPM and PDGM. To that end, trade press has reported at length about SNFs pulling back on rehabilitation services, reducing therapy staff, and allocating more resources to nursing and medical services care. In the wake of Medicare’s dramatic PAC policy changes, acute-care hospitals and health systems are reevaluating their utilization paradigm for PAC to ensure that patients are receiving the rehabilitation care they need in order to achieve optimal medical and functional recovery. The ripple effects of these changes are just starting to play out in our rehabilitation hospitals and communities, and key questions emerge regarding how and where patients will receive the vital, medically necessary skilled therapy services that are a critical part of their recovery. In light of the current landscape, I encourage you to evaluate how your organization educates and collaborates with referral sources. The new Medicare PAC policy environment presents a potential opportune time for IRFs to emphasize our unique competencies as providers of high-quality skilled therapy services and medical care, with 24/7 intensive nursing services and physician oversight. Our sector has occupied this space for decades and our experience is evident in the exceptional functional and quality outcomes our patients achieve. Health systems’ post-acute strategy are and will continue to be affected by PDPM, PGPM, bundled payments, and other yet-unknown alternative payment model that may be coming down the pike. What’s enduring, however, is the need for providers to offer high-quality rehabilitation care to patients who need it. As 2020 moves forward, I hope we can seize the opportunity to do what is in the best interest for the patients and communities we serve, in line with the core mission of AMRPA.

AMRPA Magazine / February 2020

Find new and exciting opportunities in AMRPAâ&#x20AC;&#x2122;s Career Center. Our Career Center provides services and resources to help the medical rehabilitation field meet their professional goals. All rehabilitation professionals may browse and apply for jobs at no cost, and AMRPA members will receive discounted rates for posting positions.

Visit our Career Center Here:

careercenter.amrpa.org

Begin by creating your free Career Cast account, which can be found on the top right hand corner of the website. From there, you can upload and manage multiple resumes, browse through hundreds of job postings, and even research salaries of the positions in question! AMRPA members and affiliates may also purchase Posting Packages at a standard, premium, or platinum level. AMRPA members will receive a 50% discount on all job postings. For questions about our Career Center, please contact Elizabeth Katsion, AMRPA Member Services Associate, at ekatsion@amrpa.org or 202-207-1102.

AMRPA Magazine / February 2020

Legislative Update

Congress Returns to DC with a Focus on Drug Pricing and Surprise Billing A bevy of health care items remain on the agenda for Congress in 2020. Legislative action on drug pricing and surprise billing stalled in late 2019 but are expected to resume this year, although the timing and outcome remain uncertain given the impeachment process and looming election.

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

Highlights: »» »»

»»

resident Trump will release the Fiscal P Year (FY) 2021 Budget on Monday, February 10, 2020. Impeachment proceedings have moved to the U.S. Senate, but due to disagreements between Republican and Democratic Leadership on the process, is just beginning as we go to press. The presidential election will loom large this year as Congress considers controversial health care proposals, including surprise billing and drug pricing. The final funding agreements for FY 2020 that passed at the end of 2019 included a May 22, 2020, deadline for several health care extenders – a likely driver for other health care legislation to move this year. The FY 2020 funding bills also included provisions to permanently repeal several Affordable Care Act (ACA) taxes, i.e. the medical device excise tax, the “Cadillac” tax on high-cost health plans, and the health insurance fee tax.

AMRPA Magazine / February 2020

House Democrats voted in December to approve the Elijah E. Cummings Lower Drug Costs Now Act (H.R. 3), but Senate Majority Leader Mitch McConnell (R-KY) continues to refuse to take up the bill, which relies on government price negotiation and international reference pricing. Nor has Leader McConnell committed to bringing the Senate Finance Committee-passed Prescription Drug Pricing Reduction Act (S. 2543) to the floor. Many Republican Senators are opposed to the bill’s penalties for drug price increases that are greater than inflation. A group of six Republican Senate Finance Committee members have also introduced an alternative drug pricing bill, which further complicates Finance Chair Chuck Grassley’s (R-IA) relentless efforts to pass S. 2543. January reports from several pharmaceutical companies about price increases may provide an impetus for bipartisan discussions. The president has made drug pricing a priority and the administration may release its much-awaited International Pricing Index (IPI) model proposed rule, which would tie reimbursement for certain Medicare Part B drugs to international prices. Strong Congressional opposition to the proposal could result in legislative action to modify or overturn it, while prompting renewed consideration of alternatives to reduce drug prices. Additionally, the comment period will close in March on the administration’s proposed rule for importing prescription drugs. The rule may spur additional states to consider drug importation legislation. On December 9, Senate Health, Education, Labor and Pensions (HELP) Committee Chair Lamar Alexander (R-TN) and House Energy & Commerce Committee Chair Frank Pallone, Jr. (D-NJ), along with Energy and Commerce (E&C) Republican Leader Greg Walden (R-OR), announced they reached a bipartisan, bicameral agreement on surprise medical billing legislation. The bill would require the insurer to pay at minimum the market-based median in-network rate for the service in the geographic area where the service was delivered. If the median in-network rate payment is above $750, the provider may elect to go to a “baseball-style,” binding arbitration. The bill also aims to increase prescription drug competition and create price transparency, funds public health programs (including grants for maternal health and rural health initiatives and Community Health Centers), and increases the purchasing age of tobacco to 21. Chair Alexander and House E&C leaders pushed for the revised bill to be included in the year-end spending package, but faced several obstacles including the House Ways and Means Committee subsequently releasing their surprise billing package a few days later on December 11. The Ways and Means proposal sets the patient cost-sharing for out-of-network bills at the in-network rate and also calls for a “robust reconciliation process” with clear criteria for payment resolution and pre-determined thresholds.

Notably, HELP Committee Ranking Member Patty Murray (D-WA) did not endorse Chair Alexander’s solution, and it did not make it into year-end funding legislation. Although conventional wisdom suggests that major legislation is difficult to pass in an election year, the Fiscal Year (FY) 2020 appropriations packages enacted last month established a May 22, 2020, deadline for Congress to act to extend certain expiring health care programs. This provides a pre-election, legislative vehicle for members to advance bipartisan, bicameral policy priorities, including surprise billing and drug pricing reforms. Extensions of the expiring health care programs could cost as much as $33 billion over 10 years, depending on the length of the extensions. Congress will likely seek to pay for the cost of any extenders package through advancement of other health care policies, including surprise medical billing and drug pricing, along with a number of individual health care bills already moving forward through the legislative process to address distinct issues related to specific diseases/conditions and targeted health care benefits. Impeachment Proceedings Begin in the Senate While the Senate had planned to start on the impeachment trial in early January, Speaker Nancy Pelosi (D-CA) decided to hold onto the House-passed Articles of Impeachment while Senate Majority Leader Mitch McConnell (R-KY) and Senate Minority Leader Chuck Schumer (D-NY) negotiated the process and procedure for the Senate trial. Speaker Pelosi and Sen. Schumer were demanding that certain documents and witnesses be included as part of the Senate trial, while Sen. McConnell argued that the Senate should follow the precedent of the Clinton impeachment trial and consider the question of potential witnesses and documents after the initial presentation by House managers and President Trump’s defense team. On January 15, the House voted 228-193 to appoint a team of seven managers and to officially transmit the Articles of Impeachment to the Senate. Chief Justice John Roberts was sworn in on January 16, 2020, to preside over the impeachment trial, which begins more formally on Tuesday, January 21. FY 2021 Budget Outlook The Trump administration announced that it intends to release its FY 2021 Budget Proposal on Monday, February 10, a month earlier than last year’s release of budget documents. Congress is unlikely to produce a Budget Resolution this year, given that fiscal 2021 topline numbers have already been agreed to for this upcoming year, but a final decision is forthcoming. Appropriators are focused on a June target to move through the FY 2021 Appropriations process. However, in a presidential election year there is always a chance Congress waits until the Lame Duck session to address the often controversial issues that pop up during the development of annual funding bills. New Innovation Center Leader Named The Center for Medicare and Medicaid Innovation (CMMI) has a new leader, Brad Smith, who will oversee the finalization and implementation of key models focused on radiation oncology and kidney care, among other initiatives. In light of Congressional

// House Democrats voted in December to approve the Elijah E. Cummings Lower Drug Costs Now Act (H.R. 3), but Senate Majority Leader Mitch McConnell (R-KY) continues to refuse to take up the bill, which relies on government price negotiation and international reference pricing. Nor has Leader McConnell committed to bringing the Senate Finance Committee-passed Prescription Drug Pricing Reduction Act (S. 2543) to the floor." and industry concerns about these and past models and the forthcoming IPI model, bipartisan legislation is expected to be introduced soon to establish parameters for CMMI in developing new payment and delivery models. Part I of MA Advance Notice Released On January 6, 2020, the Centers for Medicare and Medicaid Services (CMS) released Part I of the 2021 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies Comments on the proposals must be submitted by March 6, 2020. Part I lays out policies for continued transition to the Part C CMS-Hierarchial Conditional Categories (HCC) risk adjustment model. The notice also makes modifications to the methodology used to calculate the encounter data. The subsequent notice is expected soon, and the final 2021 Rate Announcement will be published by April 6. Affordable Care Act Developments The future of the Affordable Care Act (ACA) could come down to a crucial Supreme Court decision in 2020. On December 18, 2019, the Fifth Circuit Court of Appeals ruled that the ACA’s individual mandate is unconstitutional because it can no longer be considered a tax after the Tax Cuts and Jobs Act of 2017 reduced the individual mandate penalty to $0. With regard to

AMRPA Magazine / February 2020

the severability of the law, the Fifth Circuit remanded the case back to the U.S. District Court for the Northern District of Texas to determine which parts of the ACA can stay in place. On January 3, 2020, the defendant States in Texas v. United States, led by California Attorney General Xavier Becerra, filed a petition to the Supreme Court seeking immediate review of the ruling. If granted, a final decision on the fate of the ACA could be announced before the end of 2020. On January 6, the Supreme Court asked the Trump administration and Republican-led states challenging the ACA to respond to the petition by January 7. The administration argues that because the ACA remains in effect during the appeal process, the Supreme Court should not feel compelled to weigh in during an election year, whereas the Democrats are urging the Supreme Court to make a quick decision on the fate of the law. *** Lawmakers have commenced the 2nd Session of the 116th Congress amidst significant uncertainty. An impeachment trial awaits Senators, as the Trump administration braces for its impact. The May 22 deadline for several important health extenders to expire does offer an opportunity for health priorities to move legislatively this spring. Committees of jurisdiction will be working to develop a package of proposals, that likely will include small bills deemed non-controversial, and could include

AMRPA Magazine / February 2020

drug pricing and surprise billing, that is bipartisan and can move in a Presidential election year. 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. Specifically, please encourage your members of Congress to co-sponsor H.R. 3107, the Improving Seniors’ Timely Access to Care Act of 2019, which tackles some of the most challenging problems presented by prior authorization. Please reach out to your elected members and ask them to visit your hospitals and outpatient facilities – these types of visits help cultivate and strengthen Congressional champions for the field! We also urge AMRPA members to register for the upcoming Leadership Conference and Advocacy Fly-In, which will be held in Washington, D.C. March 22-24, 2020. We will help set up meetings for you and your colleagues on Capitol Hill with your members of Congress and senators, brief you on the field’s most pressing policy issues. We look forward to working with you in 2020 and hope to see you in Washington, DC, in March!

AMRPA Schedule of Events CONFERENCE DATES 2020 Spring Conference and Congressional Fly-In March 22-24, 2020 Washington, DC REGISTER TODAY! AMRPA 2020 Fall Conference October 4-7, 2020 Renaissance Dallas Hotel Dallas, Texas CALL FOR ABSTRACTS NOW OPEN! AMRPA REGIONAL MEETING SERIES Friday, May 8, 2020 Nashville, Tennessee Hosted by HCA Healthcare Friday, June 5, 2020 West Orange, New Jersey Hosted by Kessler Institute for Rehabilitation Wednesday, July 15, 2020 Denver, Colorado Hosted by Vibra Rehabilitation Hospital of Denver MEMBERS-ONLY CALLS Wednesday, March 11, 2020, Noon - 1:00 p.m. ET Wednesday, June 3, 2020, Noon - 1:00 p.m. ET Wednesday, September 13, 2020, Noon - 1:00 p.m. ET Wednesday, November 10, 2020, Noon - 1:00 p.m. ET eRehabDataÂ® CLINICAL TRAINING WEBINAR SERIES Free for eRehabData subscribers only Tuesday, February 4, 2020: Review of 60% Rule Compliance Tuesday, March 3, 2020: Managing the Patient Experience Tuesday, April 7, 2020: Nursing and Therapy Documentation Tips Tuesday, May 5, 2020: Physician Documentation Tuesday, June 2, 2020: Managing Outcomes with eRehabData Visit eRehabData.com for more Information.

Please visit www.amrpa.org for registration information.

AMRPA Magazine / February 2020

CMS Requests Legal Guidance from HHS on Applying Supreme Court Decision

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

On June 3, 2019, the United States Supreme Court issued a 7-1 decision in Azar v. Allina Health Services,1 as discussed in our August 2019 article. In its decision, the Court held that the Centers for Medicare and Medicaid Services (CMS) must use notice-and-comment rulemaking before issuing guidance that establishes or changes a substantive legal standard governing Medicare payment for services. The Court’s ruling created much uncertainty about the enforceability of Medicare guidance on inpatient rehabilitation hospitals and units (commonly referred to as IRFs). While CMS, in informal communications with representatives of the rehabilitation community, has espoused its view that the ruling does not invalidate IRF coverage guidance, no formal policy statement has been publicly issued by the Department of Health and Human Services (HHS) or CMS in response to Allina. However, an internal HHS memorandum analyzing the general impact of the ruling now sheds light on HHS’ views. Background on the Allina Case The underlying facts of the case concerned a nuanced issue involving the manner in which CMS calculates Medicare disproportionate share hospital (DSH) payments. The Court’s ruling in the case had a much broader impact, however, ultimately hinging upon the interpretation of a section of the Social Security Act (which includes the laws governing the Medicare program) that requires CMS to engage in notice-and-comment rulemaking. The Supreme Court rejected the government’s argument that the Medicare statute’s notice-and-comment rulemaking requirements do not apply to “interpretive” guidance that impacts Medicare payment, which CMS has historically issued through policy manuals and instructions to Medicare contractors. The Court determined, instead, that the Medicare statute’s notice-and-comment requirements are more expansive than those of the more broadly applicable Administrative Procedure Act (APA). In particular, the Court found that the Medicare statute does not provide an exemption for “interpretive” rules, as under the APA. This ruling opens the door to challenging other Medicare sub-regulatory guidance — such as the Medicare Benefit Policy Manual (MBPM), the Program Integrity Manual (PIM), Local Coverage Determinations (LCDs), and other guidance documents — that CMS (or its contractors) issued without notice and an opportunity to comment. The HHS Memorandum The memo, dated October 31, 2019, is from the CMS Chief Legal Officer, Kelly Cleary to Demetrios Kouzoukos, the Principal Deputy Administrator and Director of the Center for Medicare. It is specifically marked as “not releasable to the public,” but it has been available from online news sources since November 2019.

Azar v. Allina Health Servs., 139 S. Ct. 1804 (2019). Justice Stephen Breyer dissented, and Justice Brett Kavanaugh took no part in this decision because he authored the lower court’s decision in this case.

10 AMRPA Magazine / February 2020

The memo does not specifically address IRF services but does state HHS’s interpretation of Allina’s impact on CMS guidance generally: If a particular guidance document is intended to be used as the basis for enforcement actions,2 it must be issued through notice-and-comment rulemaking. With respect to CMS manuals, if the sub-regulatory guidance merely “aids” in demonstrating compliance with standards established by statute or regulation, CMS may use the guidance to provide additional clarity, but only to the extent that the underlying statute or regulation is narrow enough to create the standard being applied. The key question in determining whether guidance is valid for use in support of (not as the sole basis for) an enforcement action is whether the action could be brought without the guidance document. CMS is not precluded from enforcing payment provisions that are included in contracts or agreements that apply guidance documents, as long as those provisions are specifically referenced as an obligation of the party. Guidance documents can be used to support a determination of whether noncompliance with statutory or regulatory requirements is material to the decision to make payment for purposes of enforcement actions. LCDs are not required to be issued via notice-and-comment rulemaking, but they also may not be used as the sole support for an enforcement action. The memo also addresses whether CMS may make an “endrun” around the Allina ruling simply by retroactively codifying guidance through subsequent notice-and-comment rulemaking. The memo makes clear that, while retroactivity is permitted under the Medicare program’s governing laws and regulations, it is highly disfavored. Therefore, the memo questions whether such retroactive action by CMS would truly be effective in preserving the authority of any such guidance.

Implications on IRF Claims Under the analysis provided by the CMS Chief Legal Officer, some of the MBPM provisions on inpatient rehabilitation remain effective to support audits, but only to the extent that the underlying requirements are established in regulations. Conversely, to the extent that the MBPM provisions include requirements that are not tailored closely to the regulations, their applicability and enforceability are in question under Allina. This interpretation is consistent with the general assessment set forth in our August 2019 article, following the Allina decision. However, questions remain about whether the analysis in the memo has been communicated to the various Medicare contractors and whether CMS considers manual provisions that do not tie to the explicit language of the coverage regulations to be unenforceable under Allina. The memo’s language is non-specific enough to leave room for individuals at the agency and at the contractor level to continue to assert that the MBPM provisions merely “aid” in interpreting the narrow provisions for coverage set forth in the regulations. Ultimately, any disagreement on this point between a contractor and a provider would need to be resolved through the administrative appeals process and possibly even federal court. The IRF community will have to see how the HHS memo is incorporated and applied by CMS and its contractors. The memo can serve as additional support for IRFs that argue in the administrative appeals process that CMS and its contractors may not deny claims based solely on manual provisions that are not tied to explicit standards from the regulations, such as the MBPM’s expanded requirements for the pre-admission screening and post-admission physician evaluation. It is also possible that other health care industry sectors, especially those governed very closely by criteria established in the PIM or in individual LCDs (e.g., durable medical equipment suppliers, practitioners specializing in orthotics or prosthetics), may take up this fight. This issue warrants close monitoring going forward and we will continue to keep the rehabilitation community apprised of new developments as they occur.

Enforcement actions include overpayment collections based on audits, but not routine claims and cost reporting procedures.

AMRPA Magazine / February 2020 11

2020 Fall Educational Conference & Expo

Renaissance Dallas Hotel • Dallas, TX • October

Abstract Deadline: April 27, 2020

4-7

What would you like to discuss this year? Submit your abstracts for AMRPA’s 18th Annual Educational Conference & Expo! AMRPA encourages you to share your knowledge, case studies, and experience in these 6 categories:  Business Operations and Leadership Development  Clinical Care Delivery — A Team Approach  Regulatory, Legislative and Accreditation Matters  Marketing and Relationship Management  New for 2020! Technology, Research and Innovation  Other: Topics Outside the Box

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

#AMRPA 12 AMRPA Magazine / February 2020

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

Using the most recent two years of Medicare claims data, Dobson DaVanzo & Associates delivers inpatient rehabilitation providers with a general market-level analysis on their facilityâ&#x20AC;&#x2122;s episode spending and key performance metrics across all Medicare discharges. Benchmark your facility against state and national inpatient rehabilitation providers and find out where you stand. Dobson DaVanzo & Associates can also help you better understand how the Bundled Payment for Care Improvement (BPCI) initiative and the Comprehensive Care for Joint Replacement Payment Model (CJR) are impacting the markets.

Stay informed! Order your PAC report today. AMRPA Members Receive Reports at Discounted Rates. Visit www.amrpa.org/PAC-Market-Analysis-Reports for more information, or contact Elizabeth Katsion, AMRPA Member Services Coordinator, ekatsion@amrpa.org.

AMRPA Magazine / February 2020 13

CMG Trends

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

Beginning on October 1, 2019, the inpatient rehabilitation facility prospective payment system (IRF PPS) model shifted from FIM™-based case mix groups (CMGs) to functional items found in sections GG and H on the IRF Patient Assessment Instrument (IRF-PAI). Within eRehabData®, we modeled the changes so our subscribers would have an idea of what was coming their way with respect to Medicare reimbursement. Using the information in the April 17, 2019, IRF PPS proposed rule, we presented the 2020 Proposed Grouper Model. The proposed grouper model indicated what your anticipated case mix index (CMI) would be based on the patients admitted in the time period you designated. Providers were able to access data on the difference in average expected reimbursement such that they could assess the likely impact of the transition of the sections GG/H CMGs to their hospitals. Now that we have a full quarter of outcomes data in place, we have the opportunity to reflect on how the transition to the new CMGs has begun to impact the industry. The national CMI has increased as anticipated. At the time of writing, the CMI was 1.4210 for Medicare patients in the fourth quarter of 2019. This was up from the third quarter baseline of 1.3455, which was the last time period for the FIM™based CMGs (with the section GG/H-based CMGs taking effect October 1). This represented $1,542.43 per discharge based on the average Medicare expected reimbursement for the fourth quarter. The fourth quarter section GG/H functional scores were 49.49, while the third quarter section GG/H was 50.69. As I reflect on what has changed in the past quarter, I believe that the most obvious change was the addition of nurses in the assessment process admission scores. Prior to the anticipated CMG changes, the GG scores were largely coming from documentation provided by therapists. Since the nurses are the ones completing the first assessment upon admission, it makes sense to incorporate their observations in the functional scoring. Since we no longer have duplication of functional assessments, it should be expected that nurses capture the admission functional level in the areas that they typically assist with – such as bed mobility, transfers, toileting, eating and oral hygiene. Make sure you are analyzing your data. Based on the difference in the CMI from quarter 3 to quarter 4, the increase in the CMI for Medicare patients was 0.0755. Unless you have experienced significant changes within your organization in the last quarter, the increase in the national CMI should be similar to the CMI change that you experienced.

14 AMRPA Magazine / February 2020

If you did not experience a similar increase in your CMI, it is important to determine why. The first thing to check is the admission GG/H score and be sure that you are comparing the third quarter average to your current scores. Remember that when you compare your admission average to the weighted national or regional average, if you feel that your CMI is too low, then the group of patients that you are being compared to will be patients who are functioning at a higher level and belong in their assigned CMG. The weighted numbers are case mix adjusted. That means that the average value reported in eRehabData® is adjusted to reflect how other facilities scored patients that are case mix matched to your population. When your CMIs are too low as a result of GG/H scores that did not reflect the amount of help your patients usually required, then the group of patients you are being compared to will also not represent the burden of care of your patients. Further, evaluate your self-care and mobility averages for additional information. Remember to review the functional scoring comparison graphs for the item-by-item comparison of your admission, discharge, and change scores. While the GG/H assessment process is within your control, one of the components of the CMI that is not easily within your control is the impairment group breakdown. The consolidation of the CMGs in certain categories has the potential to reduce the CMG payments to some providers. If you have a higher than average percentage of stroke patients, you may be adversely impacted by

the relatively fewer CMGs finalized for stroke in the FY 2020 IRF PPS final rule. Where lower functioning stroke patients were broken into more groups, now there are fewer choices for matching patients to payment. If you feel that your CMI is lagging, there are a few things you can do to determine what you should be working on to get the payment that best matches your resource utilization. First, review your medical record documentation to ensure that your data collection reflects of the burden of care. Do not simply rely on your EMR to pull numbers into a report that you use to populate the IRF-PAI; instead review your records. It is impossible to know where errors may be occurring without reading what is written in the PT and OT evaluations and comparing that to the GG scores that were documented. Include nurses in the initial assessments. Read nursing notes to see what level of care was provided. Evaluate your score selection. Ensure that you are pulling the usual score. Make sure that what is documented reflects the assessments prior to the patient benefitting from therapeutic intervention. Continue to educate therapists and nurses on conducting assessments free of therapeutic intervention. Make sure to share findings from your chart audits with them. Rely on the analytical tools to highlight opportunities for improvement. If you feel that you do not have time to conduct this sort of review, seek outside assistance. This is too important to let slip away.

JOIN TODAY!

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

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

AMRPA Magazine / February 2020 15

Improved Mobility. Made Easier.™

Three Configurations Available for Your Diverse Clinical Needs

L300 Go LOWER CUFF

L300 Go THIGH STAND-ALONE CUFF

L300 Go THIGH & LOWER CUFF

for Foot Drop

for Thigh Weakness and Knee Instability

for Foot Drop and Knee Instability

The L300 Go is a functional electrical stimulation system capable of producing measurable mobility improvements for patients with foot drop and/or knee instability cause by upper motor neuron injury. L300 Go promotes recovery by activating the neuromuscular pathways required for gait.

L300Go.com | 844.674.9251

Individual results vary. Patients are advised to consult with a qualified physician to determine if this product is right for them. Important Safety Information and Risks: For Indications for Use, Contraindications, Warnings, Adverse Reactions, Precautions, and other safety information please refer to www.bioness.com/Safety_and_Risk_Information.php(also available in the L300 Go Clinician’s Guide). L300 Go®, Bioness, the Bioness Logo®, LiveOn® and Improved Mobility. Made Easier.™ are trademarks of Bioness Inc. | www.bioness.com | Rx Only

16 AMRPA Magazine / February 2020

03227

Join the Neurorecovery Revolution

TREAT

Upper Extremity Motor Impairments from Stroke, Spinal Cord Injury and Other Neurological Conditions

IMPROVE

Therapy Intensity, Patient Outcomes, Reporting Capabilities and Dialogue with Payors

ENHANCE

Staff Performance & Satisfaction, Patient Qualityof-Life and Health System ROI

WWW.BIONIKLABS.COM

AMRPA Magazine / February 2020 17

Did You Know?

All of our webinars are available online!

Missed out on a recent AMRPA webinar? Not to fear! All AMRPA webinars are available On Demand for purchase almost immediately following its recording.

W Eour B selection I N A here: R Browse https://amrpa.org/Education/Webinars/OnDemand-Webinars *AMRPA members receive a discount on all webinar recordings.

18 AMRPA Magazine / February 2020

The Next Chapter on the Unified Post-Acute Care Prospective Payment System: Summary of the November 19 CMS/RTI Technical Expect Panel

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

Since the passage of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act in 2014, the American Medical Rehabilitation Providers Association (AMRPA) has actively engaged with the entities charged with developing Unified Post-Acute Care Prospective Payment System (UPAC PPS) prototype reports – the Department of Health and Human Services (through the Assistant Secretary for Planning and Evaluation (ASPE) and the Centers for Medicare and Medicaid Services), and the Medicare Payment Advisory Commission (MedPAC). Most recently, AMRPA was well-represented at the November 18, 2019, Technical Expert Panel (TEP) convened by CMS and its’ Unified PAC PPS contractor – the Research Triangle Institute, Inc. (RTI) – which included extensive discussion on the current design elements and overarching policy goals for the CMS/ RTI Unified PAC PPS prototype report. The November TEP was the second of four TEPs currently scheduled by CMS/RTI, with the two remaining TEPs anticipated in early and late 2020, respectively. In contrast to the question-and-answer format used in RTI’s initial TEP in September 2018, RTI outlined a more specific framework and areas of focus for panelist feedback in the November session, found in greater detail below IMPACT Act: Background on Mandated Unified PAC PPS Reports and Recommendations In the five+ years since its passage, policymakers have been charged with carrying out three major mandates under the IMPACT Act: the development of quality measures in specific domains; the development and implementation of standardized patient assessment data elements (SPADE) within the four PAC payment systems; and exploration of a UPAC PPS. For the latter, the Act required a series of reports. The first was a report by the Medicare Payment Advisory Commission (MedPAC) published in June 2016.1 In developing the report, MedPAC utilized the framework from the Post-Acute Care Payment Reform Demonstration (PAC PRD) and its data to evaluate and recommend features of a prospective payment system that establishes payment rates according to patient characteristics rather than PAC setting. Since its initial publication, MedPAC has discussed implementation issues associated with the proposal – such as sequential stays and aligning statutory and regulatory requirements – among others policy issues, with further analysis expected in its 2020 reports to Congress.

MedPAC June 2016 Report to Congress

AMRPA Magazine / February 2020 19

In addition to MedPAC’s work, the IMPACT Act also directs the HHS Secretary to send a report to Congress on a technical prototype of a UPAC PPS. Similar to the MedPAC deliverable, the HHS report must outline a PPS under which payments are 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 incorporate the SPADEs required by the Act. Finally, the report must provide an analysis of the impact of the prototype on beneficiary cost sharing, access to care and choice of setting, and Medicare payments. To carry out this directive, CMS and the HHS ASPE entered into a contract again with RTI International to work on developing the UPAC PPS report and related recommendations. In September 2018, RTI held its initial TEP, to which AMRPA was invited to participate. The purpose of this panel was to discuss foundational questions to inform exploratory research on a technical prototype for a UPAC PPS. Stakeholders were encouraged to provide substantive input on ways to design a UPAC PPS where payments are based on beneficiary characteristics rather than PAC setting. RTI noted that the discussion during that TEP helped facilitate the agenda and areas of focus for the most recent November 2019 TEP. Summary of November 2019 TEP Discussion The November 18 TEP was the second of four currently scheduled meetings related to CMS/RTI’s Unified PAC PPS work; a TEP in early 2020 is intended to review RTI’s analysis to date, while a TEP in late 2020 will focus on “other considerations” for a prototype. AMRPA was represented on the November TEP by Suzanne Kauserud, Vice President of Carolinas Rehab, along with other AMRPA members and staff representing their own hospitals/systems and serving as observers. Unlike the September 2018 TEP, CMS/RTI did not ask the panelists to provide feedback on specific issues/questions at the close of the November 2019 discussion. Nevertheless, AMRPA is closely reviewing the TEP discussion and materials, and plans to engage with CMS/RTI on the key issues and open questions identified from this most recent TEP. Some selected highlights from the discussion include: Impetus for CMS/RTI Work & Current Challenges: RTI officials repeatedly provided an overview of the issues they view as necessitating discussion of a Unified PAC PPS prototype, such as: overlap in the characteristics of patients treated across PAC settings; “significantly” different Medicare payments for PAC services across settings for similar patients; analytical challenges created by the different diagnoses groups and assessments used across settings; and the siloed nature of PAC settings, as well as the fact that patients use more than one setting in their trajectory of care Case Mix Grouping: RTI unveiled a grouper model based on the Major Diagnostic Category (MDC) called “MDC+,” which has been developed for a Unified PAC PPS model and is intended to account for certain data (such as surgical procedures and conditions generally treated in PAC settings) to “better reflect the reason for a patient’s PAC stay.” The

20 AMRPA Magazine / February 2020

grouper will be primarily based on short-term acute care hospital (STACH) MS-DRG data. However, panelists raised significant concern about the utility/accuracy of continuing to use STACH data for identifying diagnosis in a Unified PAC PPS prototype, even if combined with PAC assessment data or other inputs included in the “MDC+” formula. Motor Function: RTI affirmed the inclusion of motor function in their prototype, and sought input on which motor score items would be most appropriate in the context of a Unified PAC PPS prototype Prototype Options: RTI is exploring two potential prototype models: one would largely keep the PAC silos and regulatory landscape in place, and create a new “unified clinical component” to capture patient-specific characteristics (to be added to a setting-specific indicator). The second option would provide payment for a certain period (e.g., 30 days) and would capture up to three PAC stays for a patient. This second option would also assume greater flexibility regarding provider certification requirements, among other waivers. RTI asked for input on the numerous regulatory changes that would be required to facilitate this type of model. Patient/Provider Populations: RTI asserted that their prototype work will explore “combinations” of providers, such as all acute PAC settings. With respect to patients, the model will include both community entrants and post-STACH PAC admissions Potential “PAC Navigator” Role: RTI asserted that they are considering including a patient navigator in a Unified PAC PPS to help address the challenges of care transitions, and sought feedback on ways to implement this type of function into the payment system (for example, whether it should be part of PAC providers’ conditions of participation). Numerous panelists expressed support for a PAC navigator role, but opined that this be an incentive-style program rather than one driven by financial/administrative penalties. Interoperability between PAC settings was also raised as a potential complicating factor. General Concerns re: Unified PAC PPS Implementation: Throughout the meeting, panelists raised concern with the fact that the data being used to build the prototype (20172019) reflects a period of major transition in most of the PAC payment systems, as well as the fact RTI is capturing fewer years of SPADE-reported data from the home health industry, among others. RTI repeatedly asserted that it recognizes that it is not using the “cleanest data” in its work, but that it is continually updating its analysis and incorporating stakeholder feedback as it proceeds with its mandate under the IMPACT Act. Throughout the meeting, panelists noted that while they understand that RTI has to submit a report based on data in some point in time, they raised particular concern that the 2017 data reflects care delivery patterns, PAC placements, and expenditures that vary significantly from more updated analysis.

Prototype Testing: Several panelists and observers urged RTI to consider a small-scale testing of any Unified PAC PPS prototype in light of the acknowledged analytical concerns; RTI responded that while it will include “caveats” in its report, it is not authorized to recommend that the prototype be tested prior to implementation. Medicare Advantage Impact: A handful of panelists noted that the MA program fundamentally changes each PAC setting’s case-mix and cost data, and urged RTI to factor this into a Unified PAC PPS prototype (and if not, to include the MA impact as one of the “caveats” included with the report). Discussion of High-Cost Ancillaries: Several panelists expressed support for a recommendation that high-cost ancillaries – such as chemotherapy and infusion therapy – be carved out, and that behavioral health services be added to such a carve-out policy. Panelists also expressed general support for the use of a high-cost outlier policy and interrupted stay policy under a Unified PAC PPS prototype. Report Timeframe: RTI refused to commit to a certain date for the release of their report. As previously mentioned, RTI has not yet asked panelists to respond to specific questions leading into the next TEP. Nevertheless, AMRPA is closely analyzing and planning to respond to several of the “open questions” raised during the TEP discussion, particularly related to motor function, comorbidity, and the MDC+ model. Such questions raised by TEP include: Are MDC Plus Groupings sufficiently sensitive for the first step of differentiating patients in a Unified PAC PPS case-mix methodology?

Is MDC Plus Grouping assignment based on prior acute hospitalization (when available) appropriate for case-mix grouping in a Unified PAC PPS? If not, what is an alternative method? Are there setting-specific issues that should be considered in the primary diagnosis assignment approach? How should comorbidities be defined in a Unified PAC PPS? How can approaches in the current PAC payment systems inform an approach in a Unified PAC PPS? Are there condition-specific considerations that might affect the approach to defining comorbidity in a Unified PAC PPS? Do the items proposed by RTI work “reasonably well” for measuring motor function across all settings? Are there additional setting-specific issues to be considered in for a motor function score in a Unified PAC PPS? AMRPA will keep members abreast of our continued advocacy and engagement on issues raised during the most recent TEP, as well as our strategic participation in the TEPs convened in 2020.

AMRPA Magazine / February 2020 21

ROBOTIC BODY-WEIGHT SUPPORT SYSTEM www.aretechllc.com I 800-710-0370

22 AMRPA Magazine / February 2020

Transforming Medical Rehabilitation Delivering the highest quality of patient care and outcomes through a growing national network of inpatient rehabilitation hospitals.

Proud Sponsor of the AMRPA

AMRPA Magazine / February 2020 23

Patient Success Story: Marisa Boasa Challenging the Prognosis and Fighting for Mobility By Adam Robertson, AMRPA Marketing Communications Manager

Every morning, New York native and fitness fanatic Marisa Boasa wakes up and begins her day as any other athlete does. She eats a healthy breakfast, part of a clean nutrition plan balanced in protein, fat and carbohydrates; completes a series of intensive mobility warm-ups, where she physically and mentally prepares for the day ahead; and laces up her shoes for a long-distance run, as she trains for her multiple yearly foot races around the country. Driven by a deep passion for health and overall well-being, she is your typical athlete — in all aspects but one. Marisa has multiple sclerosis. Her diagnosis came in August 2018, after she began to feel some different limitations to her mobility while training for the Philadelphia Marathon. The diagnosis also came with a daunting prognosis: “You’ll never run again.” For many, this would have been a stopping point. For Marisa, it was a challenge. What followed was a strategic rehabilitation plan coupled with a firm promise to herself and to others, a promise “to stay mobile and not stop.”

AMRPA Seeking Member Submissions of Patient Success Stories and Testimonials

In 2020, AMRPA Magazine wants to feature you! We are currently soliciting patient success stories and testimonials from AMRPA member hospitals to better showcase the outstanding work of our industry and membership. If you are interested in submitting a success story or testimonial, email Julia Scott, AMRPA Communications Coordinator, at jscott@amrpa.org.

24 AMRPA Magazine / February 2020

“It’s not easy. However, the answer is always no if you don’t ask, and in my case, it means asking for help. Having a strong network and circle of people who support me is in many ways the figurative harness to get me through some of the most difficult days. Fortunately for me, I also believe in a positive outlook, and that plays a crucial role in what I am trying to achieve.”

Often times we stand in our own way, and it’s easier to quit, but no one ever feels a level of accomplishment when they quit.”

Seeking out treatment at the Mandell Center for Multiple Sclerosis at Mount Sinai Rehabilitation Hospital, part of Trinity Health of New England, she was placed on a strict regimen of care and treatment, which involves periodic assessments to identify areas of concern and a plan to begin working toward mobility benchmarks mutually established by her and her physical therapist. “Consistency is the most important part of any form of rehabilitation,” she said. “Be consistent with therapy, medications as needed, eating well, exercise and sleep.” Just over a year later, Marisa ran the very race that she was training for when she first learned about her condition, participating in the 2019 Philadelphia Marathon last November. But she didn’t stop there. Since her diagnosis, she has put on her runner’s bib seven times, practicing the advice she gives to others facing conditions similar to hers: “Keep moving, mentally and physically.” She continued, “Often times we stand in our own way, and it’s easier to quit, but no one ever feels a level of accomplishment when they quit.” A symbol of overcoming seemingly insurmountable odds, Marisa decided to create Fight for Mobility, a grassroots initiative and platform through which she focuses on inspiring others. She is also working with congressional leadership to introduce a bill by the same name that advocates for certain accommodations provided during foot races for those with varying physically abilities. Marisa is not a traditional athlete, but it is her unconventional athleticism that inspires those living with a disability and even those that are not to keep going. And it is from her inspiring story we learn that having a disability does not mean stop. It means go. It means move. It means fight.

Stay updated on Marisa’s journey to recovery and follow her on Instagram, Facebook and Twitter. Learn more about the #powerofmedicalrehab by visiting this page on AMRPA’s website.

AMRPA Magazine / February 2020 25

CMS Actuary Details 2018 National Health Expenditures

Late last year, the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary (OA) released its annual report on National Health Expenditures. The report details overall expenditures by providers and payers, and offers comparisons in growth to prior years. This article will cover some highlights from the report.

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

Highlights:

»» »»

Hospital Spending Remains Biggest Outlier Across all Payers Overall Medicare Spending Rises 6.4%

Overall total spending increased 4.6% in 2018 compared to 2017 according to the OA. This brought total national spending to $3.6 trillion, with per capita spending of $11,172 per person. The growth rate was faster than 2017, when spending rose only 4.2% over the previous year. The OA attributed the increased growth to a private health insurance tax put in place by the Affordable Care Act (ACA), which was reinstated in 2018. However, when compared to gross domestic product (GDP), health care spending actually dropped from 17.9% of GDP in 2017 to 17.7% in 2018. Hospital spending remained the leading type of health care spending in 2018, making up 33%, or $1.2 trillion, of the total spending for the year. Hospital spending growth was nearly on par with overall growth, rising 4.5% over 2017 levels. The OA stated that it observed high rates of growth in hospital prices in 2018, but some reduction in utilization during the year as well. Medicare spending growth on hospital care also remained steady, rising 4.6% compared to 2017. The second largest type of spending after hospital care was physician and other clinical services, which totaled $725.6 billion in 2018. The growth rate for 2018 was 4.1%, lower than the 4.7% growth seen in 2017. OA attributed the slowdown in spending growth to utilization declines, and not to a slowdown in price increases. Medicare spending growth was higher for physician and clinical services, growing at a rate of 7.8% in 2018. This is notably higher than the 5.9% and 3.3% growth for Medicare seen in 2017 and 2016, respectively. Nursing facility and care in retirement communities made up 5% of total spending in 2018 for a total of $168 billion. The 1.4% growth seen in 2018 was lower than the 2% rate for 2017. Medicare spending growth on nursing facility and related care was lower than the national average, rising 1.6% in 2018. However, Medicare spending growth was still higher than 2017, when the OA reported a 1% increase in spending for nursing facility and care in retirement communities. Home health care was 3% of total national spending in 2018, totaling $102 billion. The growth rate for 2018 was 5.2%, notably higher than the 4.5% increase in 2017. Medicare spending growth on home health care was even higher, rising 5.6% in 2018, compared to only 3.2% in 2017.

26 AMRPA Magazine / February 2020

Spending on what the OA categorized as â&#x20AC;&#x153;Other Professional Services,â&#x20AC;? which includes non-physician practitioners such as physical and occupational therapists, also made up 3% of total spending in 2018. The total spending in this category was $103 billion nationally, which was an increase of 6.5% from 2017. Medicare spending growth was also higher in the category, rising 10.5% in 2018, compared to 9.6% growth in 2017. Prescription drugs made up 9% of total national spending in 2018, totaling $335 billion. This reflects a 2.5% growth in spending over 2017, compared to 1.4% growth from 2016 to 2017. The OA noted that overall retail drug prices dropped by 1% in 2018, so the overall increase in spending was attributable to utilization increases. Medicare spending growth on prescription drugs rose at a faster rate of 5.9% in 2018, also higher than the 4.8% growth rate for 2017. Among payers, private health insurance was the biggest spender in 2018, accounting for $1.2 trillion nationally. This was an increase of 5.8%, and accounted for 34% of all spending. The OA attributed this increase to the reinstatement of the ACA health insurance tax. On a per enrollee basis, private health insurance spending increased 6.7% over 2017. Medicare spending saw an even higher growth rate of 6.4% in 2018, and on a per enrollee basis growth rate of 3.7%. The OA attributed the growth in Medicare spending to Part C and Part D plans raising premiums due to the ACA health insurance tax. In total, Medicare made up 21% of all spending by payer, for a total of $750 billion in 2018. Medicaid and consumer out of pocket payments were the next two biggest sources of funding, making up 16% and 10% of total funding for 2018, respectively. More information and detailed data is available at: www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/ NationalHealthAccountsHistorical

Includes Noncommercial Research and Structures and Equipment. Includes expenditures for residential care facilities, ambulance providers, medical care delivered in non-traditional settings (such as community centers, senior citizens centers, schools, and military field stations), and expenditures for Home and Community Waiver programs under Medicaid. Note: Sum of pieces may not equal 100% due to rounding.

1 2

Includes worksite health care other private revenues, Indian Health Service, workers' compensation, general assistance, maternal and child health, vocational rehabilitaiton, Substance Abuse and Mental Health Services Administration, school health, and other federal and state local programs. 2 Includes co-payments, deductibles, and any amounts not covered by health insurance. Note: Sum of pieces may not equal 100% due to rounding. 1

SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group.

AMRPA Magazine / February 2020 27

MedPAC Formally Votes to Recommend Payment Reductions to Congress for IRFs

In December 2019 and January 2020, the Medicare Payment Advisory Commission (MedPAC) held public meeting sessions to discuss payment adequacy and updates for the four Medicare post-acute care (PAC) settings. The initial session, held on December 5, 2019, covered each PAC setting’s payment adequacy in detail and allowed for Commissioner discussion and review of draft payment recommendations. The subsequent session, held on January 16, 2020, included a brief overview of the field for each PAC setting and a formal, expedited vote on the payment update recommendations.

Remy Kerr, MPH, Health Policy and Research Manager

MedPAC PAC Setting Payment Update Recommendations for 2021 • IRF Recommendation: 5% payment reduction • LTCH Recommendation: 2% payment increase • SNF Recommendation: No update • HHA Recommendation: 7% payment reduction

MedPAC staff reiterated their prior findings that Medicare payment levels are high in inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs) relative to cost. Additionally, the SNF and HHA revised payment systems (effective in FY 2020 and CY 2020, respectively) aim to increase payment equity among settings, but may require future changes based on provider incentives. Lastly, MedPAC staff explained that settings with provider-reported functional measures may be biased in regards to data, and MedPAC continues to work toward improvements in consistency and accuracy. At the December meeting, MedPAC staff recommended a 5% payment reduction in fiscal year (FY) 2021 for IRFs. In addition to the payment update, staff restated its March 2016 recommendation for the Secretary to conduct focused medical record reviews of IRFs with unusual patterns of case mix and coding and expand the high-cost outlier pool. The 5% payment reduction has been recommended since 2017; however, Congress has not previously acted on the recommendation. In addition to the IRF payment update, MedPAC recommended for 2021: 2% payment increase for long-term care hospitals (LTCHs); 7% payment reduction for HHAs; and no update for SNFs. At the subsequent January meeting, Commissioners unanimously approved each of the recommendations via an expedited formal vote. The recommendations are expected to be included in MedPAC’s March 2020 Report to Congress. Further details for each PAC setting presentation are included below. Inpatient Rehabilitation Facilities At the December public meeting, staff provided a comprehensive overview of the state of the field for IRFs in 2018. The total number of IRFs in 2018 decreased slightly (0.7%) to 1,170, and were mostly hospital-based units. While the majority of IRFs are hospital-based, freestanding IRFs increased by 3.9%, and hospital-based units declined by 2.1% between 2017 and 2018. IRFs accounted for $8 billion of total Medicare fee-for-service (FFS)

28 AMRPA Magazine / February 2020

expenditures, and Medicare accounted for 59% of IRF discharges. The average payment per case was down slightly from $20,300 in 2017 to $20,124 in 2018. Volume increased to a total of 408,000 stays for 364,000 beneficiaries. This was an increase from 396,000 stays in 2016 and 365,000 in 2010. Additionally, IRFs treated 105.7 cases per 10,000 Medicare FFS beneficiaries, compared to 103.2 cases per 10,000 in 2016. Occupancy rates for IRFs increased by a modest 1% to 66% in 2018.

Relatively Efficient IRFs

Other IRFs

Readmission Rate

2.3%

2.6%

Discharge to SNF

4.8%

6.6%

Number of Beds

Occupancy Rate

69%

63%

Medicare Margin

17.8%

1.1%

Case Types

More neurological

More strokes

Predominant Facility Types

Freestanding, for-profit

Hospitalbased, non-profit

Source: MedPAC analysis

Quality measures for IRFs have remained stable or continued to improve since 2012. Staff cautioned commissioners that providerreported functional measures that influence payment could be at risk for bias. Risk-adjusted measure

2012

2018

Gain in motor function, in points

22.1

24.3

Gain in cognitive function, in points

3.5

4.0

Rate of discharge to community

74.4%

76.4%

Rate of discharge to SNFs

6.7%

6.6%

Potentially-avoidable hospitalization during IRF stay

2.8%

2.6%

Potentially-avoidable hospitalization within 30 days after IRF discharge

5.0%

4.8%

Source: MedPAC analysis

Staff went on to explain that financial performance varies across the setting. In 2018, the aggregate Medicare margin was 14.7% with a projected 2020 margin of 12.7%. Marginal profits (profit of admitting one additional patient) for freestanding IRFs was 41%, and hospital-based units was 20% in 2018. Staff attributed the variation in provider margins to facility cost. Facilities with lower IRF margins are often smaller units with lower occupancy, there may be a different case mix, and assessment and coding practices may vary. As in prior years, staff evaluated “relatively efficient IRFs.” MedPAC defines relatively efficient providers as those with consistently low costs and high quality. They must be in the top third performance on costs or MedPAC’s quality metrics every year over a threeyear lookback period, and cannot be in the bottom third on cost or quality metrics in any years. The staff again reported that freestanding, for-profit facilities were “disproportionately represented” among relatively efficient providers.

As in past years, the staff reported that the sector’s overall access to capital remains adequate. The large majority (75%) of IRFs are hospital-based units, and MedPAC staff reported that these units maintain good access to capital through their parent institutions. Staff did not expect any adverse effects on beneficiaries’ access to care or out-of-pocket spending as a result of the recommended payment update, but did state that the update may increase financial pressure on some providers. There was no dissent raised in either meeting regarding the IRF payment recommendation, and it passed unanimously at the January public meeting without discussion. Long-Term Care Hospitals At the December public meeting, staff reviewed the payment changes for LTCHs, and associated PPS criteria. In order to qualify as an LTCH with Medicare, a facility must first qualify as an acutecare hospital under Medicare Conditions of Participation (CoP), and have an average length of stay for certain Medicare cases of longer than 25 days. The Pathway for SGR Reform Act of 2013 altered the way LTCHs are paid. LTCHs now have a dual-payment rate structure. Cases meeting the LTCH PPS criteria are: 1) preceded by an acute care hospital discharge and 2) spend three or more days in the ICU of a referring acute care hospital or receive prolonged mechanical ventilation in the LTCH. Cases that do not meet the criteria receive a lower, site-neutral payment. Staff proceeded to update commissioners on the state of the field as of 2018. There were approximately 102,000 LTCH stays. Between 2017 and 2018 there was a 5.1% decrease in supply leading to a total of 374 LTCHs in 2018. LTCHs accounted for $4.2 billion in 2018 Medicare spending. The average Medicare payment was approximately $40,000 across all cases, and $47,000 for cases meeting LTCH PPS criteria. The sector-wide occupancy rate was 63%. The sector-wide occupancy rate decreased slightly (1%) to 63% in 2018. Quality indicators (readmission, mortality during stay and 30-days post discharge) have remained stable for LTCHs according to claims data. For cases meeting LTCH PPS criteria in 2018, 10% were

AMRPA Magazine / February 2020 29

readmitted to an acute-care hospital directly from an LTCH, 16% died in the LTCH, and 13% died within 30 days of discharge. In total, close to 40% of LTCH cases meeting PPS criteria in 2018 died or were readmitted within 30 days of LTCH discharge. Cases not meeting the PPS criteria generally had lower rates of readmission and mortality.

willingness and ability to care for Medicare beneficiaries who meet the criteria.

Staff reported that margins vary considerably across the sector, particularly between LTCHs with at least 85% of Medicare cases meeting the PPS criteria and LTCHs that do not. In 2018, the allpayer margin improved to 2.2% for all LTCHs up from 0.2% in 2017. LTCHs with a high share of patients meeting the LTCH criteria were up by 1.0% to 4.5% in 2018. The 2018 aggregate Medicare margin was 4.7%, with a projected drop to 3.7% in 2020.

Skilled Nursing Facilities At the December public meeting, staff provided an update on the state of the field for SNFs. In 2018, approximately 15,000 SNFs provided care for 1.5 million Medicare FFS beneficiaries, equivalent to 4% of all FFS beneficiaries. SNFs accounted for $28.5 billion of Medicare’s FFS 2018 spending. Additionally, FFS accounted for approximately 10% of all SNF facility days and 18% of facility revenue. SNF admission volume decreased, as was expected due to a decrease in qualifying inpatient hospital stays. SNF stays were also shorter in duration. Occupancy rates also slightly decreased in 2018 to 84%. Staff explained that the changes were expected due to alternative payment models and increasing participation in accountable care organizations (ACOs).

Each commissioner agreed with the recommendation, and it passed unanimously at the January public meeting without discussion.

Staff evaluated and presented new data regarding “relatively efficient SNFs.” Much like for IRFs, MedPAC has specific cost and quality criteria benchmarks to qualify as a relatively efficient SNF. Compared to non-relatively efficient SNFs, relatively efficient SNFs must have higher community discharge rates and lower readmission rates, higher intensive therapy days, a higher average daily census and occupancy, lower cost per day, and higher revenues per day. In aggregate, cost growth varied by share of cases meeting the LTCH PPS criteria. Cost growth was low prior to 2017 and increased to 2.7% from 2017 to 2018. LTCHs with a high share of cases meeting the LTCH PPS criteria in 2018, however, had higher cost growth from 2015 to 2017 followed by slowed growth. Staff stated that differences in cost growth reflect LTCH’s adaptation to payment system changes.

LTCHs’ access to capital is limited, which staff explained was expected given the changes in payment structure. As a result, MedPAC staff report that major chains have been diversifying their portfolios and have been strategic in purchasing, selling, and closing LTCH facilities in competitive LTCH markets. Such business practices, staff asserted, have reduced the need for capital. Staff did not anticipate any adverse effect on beneficiaries’ access to care. Staff explained the update is not expected to affect providers’

30 AMRPA Magazine / February 2020

SNF quality measures have remained stable or improved. Rate of discharge to community and potentially avoidable readmissions during SNF stay and 30 days after discharge saw improvement. Staff caveated that the functional information should be viewed with caution given that the scores are provider-reported. Staff added that changes between 2017 and 2018 could be attributable to the FY 2020 PPS update.

Staff then went on to explain that payment adequacy indicators are all positive. The 2018 aggregate margin for freestanding SNFs was 10.3%; however, across SNFs margins have significant variation. The lowest margin quartile had margins of -0.7% or lower, and the highest quartile had 19.7% or higher margins. There is also more than a 10% difference in Medicare margins for nonprofit and forprofit facilities. Staff attributed this to differences in case mix, cost

growth, per day costs, and economies of scale. The marginal profit for SNFs was 18%. Relatively efficient SNFs had a Medicare margin of 16.9%. Staff explained that the margins suggest current SNF Medicare payment is too high. CMS asserted that it revised the FY 2020 SNF PPS with the goal of moving away from incentivizing high therapy use. In other words, SNFs payments will be redistributed from high therapy needs to the medically complex. The payment changes include payments based on patient characteristics such as comorbidities, ability to swallow, depression, functional status, and cognitive impairment. Staff stated that the goal of the change was to better prepare for a unified PAC PPS, and more closely align SNF payments with other settings. Staff expressed concern about disparities between Medicare Advantage (MA) payments and FFS payments to SNFs. In three publicly traded companies operating SNFs, FFS per day payment rates were approximately 20% higher than MA payments. Staff explained that case mix characteristics between MA and FFS do not explain the payment differences. Staff explained that SNFs have adequate access to capital and buyer demand is strong but some lender wariness exists. Staff attributed the wariness to lower total margins, declining FFS SNF use, and increasing share of facility revenues from lower-paying payers (i.e. Medicaid and MA plans). Each commissioner agreed with the recommendation, and it passed unanimously at the January session without discussion. Home Health Agencies At the December public meeting, MedPAC staff concluded with an update on home health agencies. In 2018, over 11,500 agencies provided care for 6.3 million episodes for 3.4 million FFS beneficiaries. FFS spending accounted for $17.9 billion of total Medicare FFS expenditures, equivalent to approximately 2.6% of aggregate Medicare spending. Nearly 98% of Medicare beneficiaries live in a zip code with at least one HHA available. 2018 volume decreased slightly from 2017 (1.2%) to 6.3 million episodes, while volume has declined by 8.3% since 2011. This decline followed an increase of 67% between 2002 and 2011. Staff explained the decline was primarily concentrated in states that experienced higher than average growth in the prior period. Per capita utilization increased by 39% to 16.3 episodes per 100 FFS beneficiaries. The current HHA PPS factors in therapy utilization when determining payment. This incentivizes providing therapy, and as a result has led to an increasing share of total episodes. Since 2011, MedPAC has recommended the removal of therapy as a factor of payment. As part of the new payment system mentioned below, therapy will no longer be considered a payment factor for HHAs beginning in 2020. Staff provided a brief overview of HHA quality measures. The measures continue a pattern of divergence between providerreported and claims-based measures, with claims-based measures remaining relatively stable over time, and provider-reported measures showing a pattern of improvement. A new HHA payment system and case-mix system (PDGM) went into effect on January 1, 2020. The payment system is expected

to redistribute payments and maintain budget neutrality. Staff explained that the new PDGM is not intended to address high payment rates. Per the final rule, CMS anticipates payments for non-profit, hospital-based, and rural agencies will experience increased payments, while for-profit, freestanding, and urban agencies will see lower payments. A projected 4.36% payment increase is expected by CMS in 2020 due to the changes associated with the new system. Staff reported Medicare margins for HHAs continue to be high despite payment reductions mandated by the Affordable Care Act beginning in 2014. Staff did note that profit margins have remained relatively consistent despite high margins. 2018 average payments were 7% higher than in 2013 even with rebasing. HHA margins have significant variability across settings. The average margin for freestanding HHAs in 2018 was 15.3%. The lowest-margin quartile had margins of 1.2%, and the highest quartile had 24% margins. Non-profit and for-profit agencies also had significant variability (7%age point difference). Like IRFs and SNFs, staff presented new data about â&#x20AC;&#x153;relatively efficient HHAs.â&#x20AC;? HHAs classifying as relatively efficient had to meet cost and quality measure benchmarks. In 2017, 7% of HHAs were classified as such. Relatively efficient HHAs had an 8% lower median hospitalization rate, 7% higher average payment, higher annual volume, and 14% lower standardized cost per episode compared to all other HHAs. The 2017 Medicare margin for relatively efficient HHAs was 23.1%, signaling the payment rate is too high according to MedPAC staff. Staff reported that payment adequacy indicators are all positive, and that access to capital is adequate. Additionally, HHAs are less capital intensive than other settings. Staff noted that large, for-profit HHAs continue to expand and acquire new business and expand HHA operations. Each commissioner agreed with the recommendation, and it passed unanimously at the January session without discussion. *** MedPAC meeting materials and transcripts can be found at http://medpac.gov/-public-meetings-. AMRPA will continue to monitor MedPAC and associated recommendations provided to Congress in the March 2020 report.

AMRPA Magazine / February 2020 31

CMS Evaluation Finds Next Generation ACOs Led to Increased Spending in Performance Year Two

Remy Kerr, MPH, Health Policy and Research Manager

The Centers for Medicare and Medicaid Servicesâ&#x20AC;&#x2122; (CMS) administers a number of types of accountable care organization (ACO) programs. ACOs are groups of doctors, hospitals and other providers and suppliers that voluntarily form an organization with the goal of providing more coordinated care at a lower cost to Medicare patients. Participants in ACOs share accountability in cost of care, with different ACOs establishing different risk-sharing/savings provisions.1 CMS provides financial incentives to ACOS for lowering spending and meeting certain quality measures based on the beneficiary population. While most ACOs are upside risk only, some models include both upside and downside risk. For ACO participants in two-sided risk arrangements, participants can share in savings or be at risk if payments exceed a specified spending threshold. Medicare ACO models include Pioneer, Medicare Shared Savings Program (MSSP), Advance Payment, ACO Investment Model (AIM) and Next Generation ACOs (NGACO). The NGACO model requires 80% or 100% upside and downside financial risk, a much higher risk compared to other models. The primary purpose of the NGACO is to test whether strong financial incentives for ACOs alongside care coordination can improve health outcomes and lower spending for Medicare fee-for-service (FFS) beneficiaries. Additionally, the model allows CMS to test additional waivers and differing approaches for determining financial benchmarks compared to the MSSP model. The current NGACO model, which began in 2016, includes three performance years and two optional oneyear extensions. CMS recently released the evaluation report for 2017 data, the second performance year of the model. Details of the report can be found below. Performance Year Two Data In January, CMS issued the second evaluation report for NGACOs. Forty-four ACOs participated in the NGACO program in 2017, and encompassed 1.23 million beneficiaries. Twenty of the 44 total NGACOs enrolled in 100% risk for 2017. The evaluation report utilized a retrospective method to compare NGACO beneficiary cost of care to a comparison beneficiary group. The comparison group included MSSP ACO beneficiaries. The second performance year evaluation report found a statistically significant decrease in NGACO Medicare Parts A and B spending compared to care provided outside of the model; however, when factoring in shared savings payments, the model did not result in statistically significant savings. Additionally, the second evaluation report found net spending increased by $115.6 million, a statistically significant increase.

Next Generation ACO Model. (n.d.). Retrieved from https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/.

32 AMRPA Magazine / February 2020

IRF and LTCH spending reductions within the model were statistically significant. LTCH and IRF spending decreased cumulatively by 3.48% in performance years 1 and 2, and by 3.58% in performance year 2. There were no statistically significant changes in SNF spending; however, SNF stays increased by 3.4% within NGACOs both in performance year 2 and cumulatively between both performance years. The evaluation report attributed the SNF utilization and spending changes to a possible shift toward lower acuity settings for PAC, use of preferred provider networks, and three-day SNF waivers. In regards to quality, the report also found no significant changes in quality measure outcomes. The measures evaluated were preventable hospital admissions, hospital readmissions and hospital readmissions following SNF stays.2 As a result of the findings, CMS Administrator Seema Verma stated in a recent Health Affairs blog post that CMS has made changes to how NGACO financial benchmarks are calculated for 2019 and 2020. The baseline will incorporate two years of “prior-year” data going forward rather than one year of data. Additionally, an “attained performance adjustment” will be included. The adjustment will take into account regional expenditures for the benchmark calculation in order to adjust for local trends.

Of interest to AMRPA members, the evaluation report noted that between 2016 and 2017, there were changes in post-acute care (PAC) spending in some settings, leading to minimal declines in gross Medicare spending. The savings were offset, however, by the shared savings payments.

To learn more about NGACOs visit https://innovation.cms.gov/ initiatives/Next-Generation-ACO-Model/ and for the complete second year evaluation report visit https://innovation.cms.gov/ Files/reports/nextgenaco-secondevalrpt.pdf.

(Next Generation ACO Second Evaluation Report, n.d.) Retrieved from https://innovation.cms.gov/Files/reports/nextgenaco-secondevalrpt.pdf

AMRPA Magazine / February 2020 33

Check out

Engage AMRPA!

An online community forum enabling a private social network for AMRPA members to form communities, collaborate, manage industry profiles, and connect with peers and colleagues. On Engage AMRPA, members are also able to:  View AMRPA Upcoming Events  Listen to AMRPA Member’s Only Calls  Read the latest AMRPA Comment Letters  And much more!

engage.amrpa.org/home

Come see what people are talking about!

34 AMRPA Magazine / February 2020

ADVERTISING RATES:

Full page - $1500 Half page - $1000 Third page - $750 Ads may be B&W or full color.

ADVERTISING CONTACT: Julia Scott Phone: +1-202-207-1110 Email: jscott@amrpa.org

ADVERTISE IN OUR MAGAZINE

DISCOUNTS FOR MEMBERS

AMRPA Magazine / February 2020 35

AMRPA & eRehabData ÂŽ 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. 36 AMRPA Magazine / February 2020

AMRPA Magazine | February 2020

Articles inside

CMS Evaluation Finds Next Generation ACOs Led to Increased Spending in Performance Year Two

CMG Trends

Patient Success Story: Marisa Boasa Challenging the Prognosis and Fighting for Mobility

The Next Chapter on the Unified Post-Acute Care Prospective Payment System: Summary of the November 19 CMS/RTI Technical Expect Panel

CMS Actuary Details 2018 National Health Expenditures

Letter from the Chair

MedPAC Formally Votes to Recommend Payment Reductions to Congress for IRFs

CMS Requests Legal Guidance from HHS on Applying Supreme Court Decision

Legislative Update