January 2019

January 2019 • Vol. 22, No.1

Addressing Regulatory Relief

January 2019 • Vol. 22, No. 1

The official publication of the American Medical Rehabilitation Providers Association (AMRPA) Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive 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 Brian McGowan AMRPA Design and Layout

AMRPA Magazine, Volume 22, Number 1 AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA).

AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities.

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Table of Contents Letter from the Chair

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Legislative Update

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Regulatory Changes Continue to Threaten ACA Coverage of Orthotics and Prosthetics

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The Rest of the IRF-PAI

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AMRPA Submits Comments to the Department of Health and Human Services on Patient Social Risk Factors

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CJR Evaluation Report Finds Significant Drop in Inpatient Rehabilitation Use and Hospital Concerns About Care Stinting

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CMS Expands MIPS to Therapists and Other New Clinicians in 2019 Final Rule

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2019 Physician Fee Schedule Final Rule Removes Functional Reporting for Therapists, Changes Outpatient Physician Billing and Documentation Requirements

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HHS Report on Electronic Health Record Adoption and Interoperability Among SNFs and HHAs

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AMRPA Schedule of Events

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Functional Status Data Improves Identification of High-Cost Cases in Comprehensive Care for Joint Replacement

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Study Analyzes Variation in Community Discharge Rates After Inpatient Rehabilitation

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Medication-Related Adverse Events and Non-Elective Readmission in Acute Ischemic Stroke

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Study Examines Patients Dissatisfaction with Hospital-to-SNF Care Transitions

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Traumatic Brain Injury Readmission Rates and Reasons in a Rural Population

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Latest Research Findings

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House and Senate 1st Session 116th Congressional Calendar

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POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 750, Washington, DC 20045

AMRPA Magazine / January 2019

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Letter from the Chair

Addressing Regulatory Relief We recently held a well-attended AMRPA membership call. The issue of regulatory relief kept emerging. The topic was worthy of further investigation.

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

Regulatory relief is an important issue affecting members of our association at all levels, from clinicians to administrative staff. Documentation requirements alone draws resources away from what the primary work of our clinical staff, patient-centered care.

AMRPA has taken various approaches to address regulatory relief. We have formally responded to Congressional requests for information (RFIs) on this subject. For example, we have responded to requests from the House Committee on Ways and Means Subcommittee on Health and on the “Patients Over Paperwork and Regulatory Burden Reduction” effort by the Centers for Medicare and Medicaid Services (CMS).

Our comments to government entities have focused on some key areas. These areas have included the following: revising the IRF classification criteria including the ’60 Percent Rule,’ coverage rules for the delivery of therapy such as the ‘3-hour rule’, ensuring new unit parity, improving Medicare Advantage access to our hospitals, reducing unnecessary documentation requirements, facilitating alternative payment models, payment flexibility, reforming audits, denials and appeals and creating a Post-Acute Care Advisory Council.

Our efforts have concentrated on the “lowest hanging fruit” that might be accomplished with minimal added impact to the Medicare program.

In support of regulatory relief, we also participated in the House Committee on Ways and Means Health Subcommittee’s Red Tape Relief Initiative. During one of their provider roundtables, we addressed many of the issues noted above. The Committee did release a report in August which outlined major post-acute care issues such as documentation, flexibility in correcting minor claim submission, flexibility for certain health care requirements and the need to have more engagement and transparency between CMS and post-acute care providers.

While we have seen some small concessions from CMS, such as physician documentation requirements, much more work needs to be done. As such, the association has developed a legislative action plan with heavy emphasis on efforts to reduce many regulatory burdens. We will also continue to fight to ensure our patients have access to needed services through Medicare Advantage/Managed care programs.

Our association hears these issues from our members and we continue to put them front and center in our efforts to seek relief. In addition to those mentioned above, we will focus on various CMS initiatives including responses to requests for information and seeking legislative pathways. We will continue to keep our membership involved and we welcome your input on any of these issues.

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AMRPA Magazine / January 2019

Save The Date

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

AMRPA Magazine / January 2019

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Legislative Update

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

Highlights: »»

Judge declares the Affordable Care Act (ACA) unconstitutional, sending shockwaves through the health care system. The ruling does not immediately impact the law, and an appeal is expected by Democratic Attorney Generals.

»»

The results of the midterm elections will test whether a divided Congress can find common ground and effectively legislate.

»»

Rep. Nancy Pelosi (D-CA) made it through the first round of votes by the Democratic Caucus to be House Speaker in the new Congress, despite some interparty critics.

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As expected, Sens. Mitch McConnell (R-KY) and Charles Schumer (D-NY) will continue to lead their respective parties in the 116th Congress.

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The early health agenda of the 116th Congress, led by Democrats in the House, may focus on improving the ACA’s Exchanges, lowering prescription drug costs, and balance billing.

Federal Judge Strikes Down ACA On Friday, December 14, 2018, a federal district judge ruled that the individual mandate included in the Affordable Care Act (ACA) is unconstitutional, because Congress repealed the penalty provisions as part of last year’s tax reform bill. Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas further concluded that the individual mandate cannot be severed from the rest of the ACA; therefore, the entire law is invalid. Since the judge issued a declaratory ruling rather than an injunction against enforcement of the ACA, however, the current law remains in effect while the decision is being appealed.

// President Trump enjoyed control of all three branches of government by his party.

This has now ended and heralds a more challenging legislative environment for all interests – Republicans, The case ultimately could make its way to the U.S. Supreme Court.

Democrats and those The Court’s rulings often favor severability, which holds that in the advocacy when a portion of a law is found unconstitutional, the rest of the community seeking to law should be preserved. Notably, the Supreme Court’s 2012 ruling enact legislation. on the ACA – which preserved the The White House confirmed that the ACA will remain in place while the ruling is challenged, and the Centers for Medicare and Medicaid Services (CMS) noted that it will continue to implement the law – specifically stating in a release that the work of the Innovation Center will not be affected. The appeal to the conservative-leaning Fifth Circuit Court of Appeals will be led

by California Attorney General Xavier Becerra and several other Democratic Attorneys General.

individual mandate while striking down a provision requiring states to expand Medicaid – implied that the law was severable.

The outlook for legislative action in Congress is unclear at present. The President was quick to declare victory on Friday night, calling the ACA an “unconstitutional disaster”

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and calling for Congress to pass a new health care law to replace it. Senate Minority Leader Chuck Schumer (D-NY), meanwhile, said the ruling was “based on faulty legal reasoning,” while House Minority Leader Nancy Pelosi (D-CA) called the district court’s “absurd ruling” an “assault on people with pre-existing conditions and Americans’ access to affordable health care.”

Incoming Senate Finance Committee Chairman Charles Grassley (R-IA) committed to holding hearings on what he called the “fatally flawed” ACA. House Ways and Means Chairman Kevin Brady (R-TX) and House Energy and Commerce Committee Chairman Greg Walden (R-OR) expressed support for preserving the ACA’s pre-existing condition protections and urged action on bipartisan health care reform legislation.

Congressional Leadership Elections Held Post-Midterm Election The 2018 midterms were a “change” election in which Democrats regained control of the House of Representatives, winning a total of 40 previously Republican-held seats with the North Carolina seat still being challenged due to potential vote fraud. Over several elections, In 2016 Republicans had widened their majority in the House by expanding their control of ex-urban and close-in suburban districts. This process reversed itself significantly with Democrats winning control of many suburban and further out districts. Republicans did, however, solidify – and in some cases increased – their margins in purely rural areas. When the 116th Congressional session convenes in January 2019, the Democratic Party in the House will hold 235 seats, returning the party to power for the first time in eight years. Republicans will hold 200 seats, down from 236.

Republicans strengthened their position in the Senate with a net increase of two seats. Republicans enjoyed a significant advantage in the Senate given the disproportionately large number of Democratic seats that were in play this election cycle. The net effect of the election is a major shift in power in Washington. President Trump enjoyed control of all three branches of government by his party. This has now ended and heralds a more challenging legislative environment for all interests – Republicans, Democrats and those in the advocacy community seeking to enact legislation. The final Senate composition for the 116th Congress will be 53 Republicans to 47 Democrats (including two Independents who caucus with the Democrats).

Shortly after the election, the parties held their respective leadership elections. Despite rumblings from several current members of the House and newly elected Democratic members, Rep. Nancy Pelosi (D-CA) will likely reclaim the Speaker’s gavel in January. On November 28, the Democratic Caucus voted 203-32 to elect her as House Speaker. The full House will vote on her nomination on January 3, 2019, where she can only lose 17 votes. The Caucus elected Rep. Steny Hoyer (D-MD) as Majority Leader, Rep. James Clyburn (D-SC) as Majority Whip, Rep. Ben Ray Lujan Jr. (D-NM) as Assistant Leader, Rep. Hakeem Jeffries (D-NY) as Caucus Chair, and Rep. Katherine Clark (D-MA) as Vice Caucus Chair. Rep. Karen Bass (D-CA) was elected to chair the Congressional Black Caucus. House Republicans elected

current Majority Leader Kevin McCarthy (R-CA) to lead them in the Minority. Current House Speaker Paul Ryan (R-WI) is retiring at the end of 2018. Additional Leadership positions in the House Republican Party include the following: Minority Whip Steve Scalise (R-LA), Conference Chair Liz Cheney (R-WY), NRCC Chair Tom Emmer (R-MN), Policy Committee Chair Gary Palmer (R-AL), Conference Vice Chair Mark Walker (R-NC), and Conference Secretary Jason Smith (R-MO).

On November 14, Senate Republicans re-elected Sen. Mitch McConnell (R-KY) as the Republican leader. Sen. Chuck Grassley (R-Iowa) is Senate President Pro Tempore; Sen. John Thune (RSD) is the new Senate Republican Whip; John Barrasso (R-WY) is Senate Republican Conference Chair; Sen Roy Blunt (R-MO) is Senate Republican Policy Committee Chair; Sen. Joni Ernst (R-IA) is Senate Republican Conference Vice Chair; and Sen. Todd Young (R-IN) is the National Republican Senatorial Committee (NRSC) Chair. Senate Democratic Leadership remains mostly the same as the prior Congress. Sen. Charles Schumer (D-NY) will continue to serve as the Senate Democratic Leader and Chair of the Conference, Sen. Dick Durbin (D-IL) will continue to be Democratic Whip, and Sen. Patty Murray (D-WA) is the Assistant Democratic Leader. Chair of the Democratic Policy and Communications Committee is Sen. Debbie Stabenow (D-MI), Vice Chairs of the Conference are Sen. Elizabeth Warren (D-MA) and Sen. Mark Warner (D-VA), Chair of Steering Committee is Sen. Amy Klobuchar (D-MN), Chair of Outreach is Sen. Bernie Sanders (I-VT), Vice Chair of the Democratic Policy and Communications Committee is Sen. Joe Manchin (D-WV), and Senate Democratic Conference Secretary is Sen. Tammy Baldwin (D-WI).

Congressional Committee Announcements Some changes are in store for key Committees of jurisdiction in the 116th Congress. With Democrats now in control of the House, Rep. Richard Neal (D-MA) will head the House Ways and Means Committee. Most expect Rep. Lloyd Doggett (R-TX) to chair the Health Subcommittee, but we expect a formal announcement from the Committee in the near future. Rep. Kevin Brady (RTX) will be Ranking Member of the Full Committee. Rep. Frank Pallone (D-NJ) is set to chair the House Energy and Commerce Committee, while Rep. Greg Walden (R-OR) will be the Ranking Member. Rep. Anna Eshoo (D-CA) is expected to lead the Health Subcommittee.

In the Senate, Lamar Alexander (R-TN) will continue to chair the Health, Education, Labor and Pensions (HELP) Committee, and Sen. Patty Murray (D-WA) will stay on as Ranking Member.

Additionally, Sen.-elect Jacky Rosen (D-NV) will replace Sen. Michael Bennet (D-CO) on the Committee.

Sen. Charles Grassley (R-IA) will chair the Finance Committee, taking over for retiring Sen. Orrin Hatch (R-UT), and Ron Wyden (D-OR) will continue as Ranking Member. Additionally, Sens.

Catherine Cortez-Masto (D-NV) and Maggie Hassan (D-NH) will take the seats of Sens. Claire McCaskill (D-MI) and Bill Nelson (DFL), who lost their reelection races in November.

AMRPA Magazine / January 2019

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End of Year Health Care Legislation Introduced On December 10, House Ways and Means Chairman Kevin Brady (R-TX) introduced new tax legislation that would affect revenue measures that were part of the Affordable Care Act (ACA).

The bill would postpone the medical device tax until 2025 and delay the Cadillac tax on high-end employer health plans until 2023. The bill further delays the health insurance tax to 2022 and eliminates the tanning tax altogether. On December 11, Committee Republicans also introduced several health care bills as part of the Committee’s Medicare Red Tape Relief Project.

The bills focus on rural hospitals and post-acute care. H.R. 7248, the Reducing Administrative Burden and Becoming Increasingly Transparent Act, introduced by Rep. Kenny Marchant (R-TX) requires the Secretary to solicit comments from PAC providers on regulatory alignment issues with respect to a PAC prospective payment system (PPS). Other legislation aims to improve prior authorization in Medicare Advantage plans. Given the late timing of the Congressional session, these bills appear to be policy markers rather than legislation with realistic prospects for being enacted in the near future.

A Look at 2020 While Republicans had a plum map in 2018, the tables will turn in 2020, a presidential election year. Whereas Republicans in 2018 only had to defend 9 seats compared to Democrats’ 24 seats, in 2020, the GOP will be forced to defend 21 while Democrats will only have 12 seats in cycle.

Where the Senate Republicans seats are up is also of keen interest already. Several GOP senators will be running in what are considered highly competitive swing states. Republicans representing six states—Arizona, Colorado, Georgia, Iowa, Maine and North Carolina—are likely to face spirited challenges. Additionally, Democrats are likely once again to target Senate Majority Leader Mitch McConnell (R-KY), attempting to recruit a candidate who will make the race competitive in a conservative state.

Of those competitive states, all except Colorado broke for President Trump in 2016, although by slim margins. Maine gave a single electoral vote to President Trump while giving the rest to Hillary Clinton. Looking further back to 2012, President Obama carried Colorado, Maine and Iowa, while Arizona, Georgia and North Carolina voted for Mitt Romney.

Though the map is much more generous to Democrats in 2020 compared to 2018, they will have to defend a couple of seats that are likely to draw completive challenges. The Alabama Senate seat currently held by Senator Doug Jones will be at the top of the Republicans’ priority list. The GOP also is likely to invest heavily in races in New Hampshire and Virginia.

As it pertains to Governorships, three southern states—Kentucky, Louisiana and Mississippi—will hold statewide elections in 2019.

All three states handily voted for President Trump and Mitt Romney. Deep-red Louisiana currently has a Democratic governor that will likely field a strong GOP challenger, and the Kentucky gubernatorial race is already shaping up to be a competitive race.

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In 2020, 11 states will hold gubernatorial elections, including the Trump-Romney states of Montana and North Carolina, both of which have Democratic governors. Meanwhile, Republican incumbents will be eligible for reelection in Vermont, a deeply Democratic state, and New Hampshire, which will be a target of investment from presidential campaigns.

Lame Duck Session Overview Not surprisingly for a lame duck Congressional session, the final weeks of the 115th Congress did not play out as anticipated. Several days into the lame duck, it was clear that political infighting would not allow for a smooth passage of a final spending package for the remaining Fiscal Year (FY) 2019 Appropriations. Even the Republican tax extender package fell apart in the House. Ceremonies honoring former President George H.W. Bush also complicated the legislative agenda during the first week of December. On December 3, the House Appropriations Committee released a two-week stopgap Continuing Resolution that pushed the funding deadline until December 21.

With the FY 2019 Labor-HHS Appropriations bill already enacted, there are few vehicles for health-related legislation. Historically, Congress has passed year-end Medicare packages, but it may be different this December with no expiring provisions to extend (i.e., “extenders”). As we go to print there is an appetite and final legislative push for several health bills considered noncontroversial because of their bipartisan support. Besides the federal government funding bill, other vehicle possibilities could include a Tax Extender package, reauthorization of the Pandemic and All-Hazards Preparedness Act (PAHPA), reauthorization of National Flood Insurance, and/or the Farm Bill. These bills could potentially all be rolled into a final Omnibus package.

116th Congress Health Care Outlook House Democrats are expected to focus on several health care priorities in the 116th Congress. Democrats will look to shore up the Affordable Care Act’s (ACA) insurance exchanges, perhaps through restoring cost-sharing reduction payments or reinsurance/risk corridors. Democrats may also focus on the Trump administration’s implementation of ACA requirements and authority for Medicaid actions. With the Republican challenge to ACA pending in federal court, protection for individuals with pre-existing conditions remains a priority issue.

Democrats are expected to prioritize efforts to bring down prescription drug costs, a rare area of potential cooperation with the Trump administration and incoming Senate Finance Chair Charles Grassley (R-IA). It is expected that Democrats will pursue investigations, subpoenas, and calls for transparency.

Other health care areas of focus may be “surprise” medical billing, which also has bipartisan support. While legislative action is unlikely on “Medicare for All” bills, the issue will arise in Committee hearings and floor debates.

Trump Administration “Drops” New Drug Pricing Rule On November 26, 2018, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule, “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-ofPocket Expenses.” This proposed rule aims to build on President

Trump’s blueprint to lower drug costs and reduce out-of-pocket costs for patients. The regulation includes several controversial policies, such as allowing Part D plans to exclude drugs in “protected” therapeutic classes from their formularies, if the manufacturers raise prices faster than inflation or if a drug is a new formulation of drugs already on the market. The rule would expand the use of step therapy, including for protected class drugs, by Part D plans and for Part B drugs in Medicare Advantage plans.

CMS is also proposing that each Part D plan adopt a provider Real Time Benefit Tool in order to apprise prescribers when lowercost alternative therapies are available under the beneficiary’s prescription drug benefit. Additionally, the proposed rule restricts gag clauses in Part D. The rule is estimated to save the federal government $1.85 billion over ten years.

The Senate and House are now likely to adjourn on December 21 when the next short-term Continuing Resolution expires.

As we go to print, 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. President Trump made it very clear during a televised meeting with current House Minority Leader Nancy Pelosi (D-CA) and Senate Minority Leader Chuck Schumer (D-NY) that he will not hesitate to shut down the federal government over border wall funding. The President later indicated he may support another short-term CR into early January 2019, in order to resume negotiations for border wall funding and not shut down the federal government over the end of year holidays.

The 116th Congress is set to begin on January 3, 2019. The election results mean we will have more than 100 new members of Congress. On our key committees of jurisdiction, we will face a significant number of new members, with as many as 12 new members of Ways and Means and an equal number on Energy and Commerce. While the Senate did not flip, we will be dealing with a new Finance Committee Chair, Chuck Grassley (R-IA), who has formerly chaired the committee, due to the retirement of current Chair Orrin Hatch (R-UT). Likely significant amount of staff turnover will occur as various new House and Senate Committee Leaders settle in.

We encourage AMRPA member hospitals to take time to reach out now and educate Congressional Representatives, especially incoming Members, about how critically important and medically necessary rehabilitative care is for its patients. Now is the moment to reach out to your newly elected Members and ask them to visit your hospitals and outpatient facilities. Please cultivate strong Congressional champions for the field!

AMRPA Magazine / January 2019

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Regulatory Changes Continue to Threaten ACA Coverage of Orthotics and Prosthetics

Peter W. Thomas, Principal, The Powers Law Firm

The Trump administration has expressed frustration with Congress’ inability to repeal and replace the Patient Protection and Affordable Care Act (“ACA”) ever since the president rode into office on a wave of anti-ACA sentiment. However, an alternative strategy, a regulatory approach, has been much more effective than the congressional pathway over the past two years in transforming the private insurance market. The regulatory changes stem from the administration’s desire to allow states greater flexibility to administer private insurance, removing ACA insurance rules, and thereby making health insurance less costly to purchase. When private insurance is less costly, even if the benefit packages are less comprehensive, argues the administration, more people will purchase health insurance.

Critics of this argument, however, believe that such regulatory actions are merely an attempt to undermine the ACA’s patient protections and insurance marketplace, made under the guise of increased state flexibility. These critics argue that replacing ACAbased health plans with “junk” insurance that does not have to meet a federal standard will result in consumers having a false sense of confidence that they are covered when many of these plans will restrict benefits and impose other discriminatory insurance practices when consumers need health care the most.

In keeping with the view that ACA plans impose too many requirements and are too expensive, the Trump administration has promulgated regulations in the past year expanding the availability of association health plans (“AHPs”) and short-term limitedduration insurance (“STLDI”), which are exempt from many of the ACA’s consumer protections.1 The administration also finalized regulations and guidance documents that provide additional flexibility to states in establishing essential health benefits (“EHB”) benchmark plans, enhance the role of states in the certification of qualified health plans, and provide states with additional flexibility in the operation and establishment of Exchanges.2 Recently, the Trump administration published guidance on health insurance waivers, known as “Section 1332 State Innovation Waivers,” which are now being renamed “State Relief and Empowerment Waivers,” that states may use to modify certain health insurance requirements under the ACA. As the 116th Congress convenes in early January, House Democrats will likely examine options to deliver on their campaign promise to protect the ACA, especially individuals with pre-existing conditions. Given the makeup of Congress, however, particularly the Senate, there are limited vehicles through which House Democrats can effectively reverse the Trump administration’s regulatory efforts.

1. Short-Term, Limited-Duration Insurance, 83 Fed. Reg. 38,212 (Aug. 3, 2018); Definition of “Employer” Under Section 3(5) of ERISA—Association Health Plans, 83 Fed. Reg. 28,912 (June 21, 2018).

2. Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2019, 83 Fed. Reg. 16,930 (Apr. 17, 2018).

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The Trump Administration Issues Guidance on Section 1332 State Innovation Waivers On October 24, 2018, the Department of Health and Human Services and the Department of the Treasury (the “Departments”) published guidance changing the manner in which the Departments review and approve Section 1332 State Innovation Waivers (the “October 24 guidance”).3 Section 1332 of the ACA permits states to waive certain provisions of the ACA regarding health insurance coverage. These waivers provide states with flexibility to pursue alternative health insurance market arrangements, subject to federal government approval. Congress envisioned Section 1332 to allow states to innovate in their insurance markets, as long as the Secretary of Health and Human Services and/or the Secretary of the Treasury (the “Secretaries”) grant the state’s waiver proposal, which must satisfy the following four requirements related to comprehensiveness, affordability, comparability, and federal deficit neutrality (the “statutory guardrails”): 4 1. Provide coverage that is at least as comprehensive as the coverage defined in the ACA and offered through Exchanges established under the ACA as certified by Office of the Actuary of CMS based on sufficient data from the state and from comparable states about their experience with programs created by the ACA and the provisions of the ACA that would be waived; 2. Provide coverage and cost sharing protections against excessive out-of-pocket spending that are at least as affordable as the ACA would provide; 3. Provide coverage to at least a comparable number of its residents as the provisions of the ACA would provide; and 4. Not increase the federal deficit.

In 2015, the Departments issued guidance on how they would examine applications for waivers under Section 1332.5 In revising the 2015 guidance, the Trump administration’s October 24 guidance reinterprets the statutory guardrails, which could open the door for states to implement significant changes to their insurance markets. In addition, the October 24 guidance announced that the secretaries will favorably consider waiver applications that advance some or all of the following five principles: 1) Provide increased access to affordable private market coverage; 2) encourage sustainable spending growth; 3) foster state innovation; 4) support and empower those in need; and 5) promote consumer-driven healthcare.

Previously, Section 1332 State Innovation Waivers had to show that actual comprehensive coverage was available to “at least a comparable number of its residents.”6 According to the October 24 guidance, the Secretaries will now be able to consider waivers that simply provide access, i.e., availability, to comprehensive and affordable coverage, as opposed to analyzing the type of

coverage residents actually purchase. The new lower standard may lead to the approval of waivers where less comprehensive or affordable coverage options are present. Furthermore, this may lead to consumers opting out of more expensive, comprehensive coverage to enroll in less expensive, less comprehensive plans.

States will no longer have to ensure their waiver applications provide for coverage that meets the minimum essential coverage level, i.e., “essential health benefits” or “EHB” package, mandated under the ACA. Instead, the Departments may approve waivers that also include STLDI and AHPs as acceptable forms of private coverage. In determining whether a waiver application’s coverage is comprehensive, States will compare access to coverage under the waiver to the state-selected EHB benchmark plan, which could be the state’s own EHB benchmark plan, or any other state’s benchmark plan chosen for purposes of the waiver application. The long and the short of this is increased risk that essential health benefits such as “rehabilitation and habilitation services and devices” will no longer be covered, or covered to the same extent, under these Section 1332 waivers.

Regarding affordability, the Departments will evaluate whether a waiver makes coverage more affordable based on all state residents, regardless of the type of coverage they would have chosen without the waiver. Previously, states evaluated waivers based on the waivers’ effects on particular groups of individuals, including vulnerable populations with chronic disease, for instance. Under the new guidance, Departments will consider the aggregate effects of the waiver.

Logistically, the Department of Health and Human Services indicated that it will allow www.healthcare.gov, the online platform for consumers to purchase individual market plans, to accommodate state-specific variations. This new option may allow for more customization to account for differences between state offerings on the site. In addition, under the ACA, a state’s Section 1332 waiver application must provide assurances that the state enacted a law permitting it to implement the waiver provisions. Now, the guidance suggests it is relaxing this requirement, as well as the requirement that the state demonstrate the new waiver has a budget neutral impact on the federal budget.

The October 24 guidance has significant and negative implications for some consumers, mainly individuals who are older, less healthy or have pre-existing conditions, chronic conditions or disabilities. Questions have also been raised regarding whether the October 24 guidance comports with the intent and plain language of the ACA. However, advocates in favor of added state flexibility cite the prospects for additional coverage options that are less expensive and more affordable, primarily benefitting individuals who are younger, healthier and fortunate enough to not encounter major injury or illness.

3. State Relief and Empowerment Waivers, 83 Fed. Reg. 3,575 (Oct. 24, 2018).

4. 4 2 U.S.C. § 18052(b)(1). The Secretary of Health and Human Services reviews requests for waivers relating to the provisions described in 42 U.S.C. § 18052(a)(2)(A)-(C).

Id. § 18052(a)(6)(A). The Secretary of the Treasury reviews requests for waivers relating to the provisions described in 42 U.S.C. § 18052(a)(2)(D).

5. Waivers for State Innovation, 80 Fed. Reg. 78,131 (Dec. 16, 2015).

6. 42 U.S.C. § 18052(b)(1)(C).

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The Trump Administration Releases Four New Waiver Concepts In addition to the new state waiver guidance, on November 29, 2018, the Centers for Medicare and Medicaid Services (CMS) published four “waiver concepts” to aid states in how they may take advantage of the new flexibilities set forth in the October 24 guidance.7 The four wavier concepts are: 1) account-based subsidies; 2) state-specific premium assistance; 3) adjusted plan options; and 4) risk stabilization strategies. These concepts, however, are not required to be addressed in the waiver applications themselves.

Under the account-based subsidies waiver concept, a state could “direct public [ACA insurance] subsidies into a definedcontribution, consumer-directed account that an individual uses to pay for health insurance premiums or other health care expenses.”8 Funding for this account could come from pass-through funding made available by waiving the Premium Tax Credit (PTC) or the small business health care tax credit, in addition to other sources (such as individual and employer contributions). This would essentially allow ACA insurance subsidies to be spent on direct health care out of a health savings-type of an account, without a requirement to use the subsidies for the purchase of an insurance product.

According to the state-specific premium assistance wavier concept, states could create a new, state-administered subsidy program funded by federal pass-through funding made available by waiving the PTC. Under the adjusted plan options waiver concept, states could “provide financial assistance for different types of health insurance plans, including non-Qualified Health Plans.”9 For example, the state may expand the availability of catastrophic plans by waiving Section 1302(e)(2) of the ACA. Lastly, the risk stabilization strategies concept provides states “more flexibility to implement reinsurance programs or high-risk pools.” 10 All of the models allow states to accept federal ACA subsidies without the requirement to provide health insurance in the manner anticipated by the drafters of the ACA. These approaches may be attractive to certain young and healthy enrollees who cannot—or do not want to—spend the amount it takes to afford a health plan that meets the consumer protection requirements that undergird ACA plans. Individuals who are older or have health care conditions or disabilities will likely reject these approaches in favor of more comprehensive ACA insurance.

In the end, the ACA marketplaces will likely suffer from adverse selection as the insurance pool is bifurcated between younger and healthier versus older and less healthy enrollees (who will remain in the ACA insurance pool, driving costs up further).

However, adverse selection assumes that states that pursue these waiver models will also maintain access to ACA-compliant insurance plans in their state. If states adopt these models to the exclusion of ACA insurance, older and less healthy enrollees will have no choice but to participate.

Backlash from House Democrats Many House Democrats campaigned this election cycle on the promise of protecting the ACA and, in particular, individuals with pre-existing conditions. As the 116th Congress convenes in January, House Democrats, who are now in the majority, will likely examine all options to deliver on their campaign promises.

However, given that Republicans maintain control of the Senate, the current makeup of the 116th Congress limits the legislative options available for reversing the Trump administration’s regulatory actions.

Although Congress has the authority to enact legislation overriding regulatory and sub-regulatory guidance, including the October 24 guidance, the likelihood of such legislation passing in the Republican-controlled Senate is slim. Even if such a measure could pass both chambers of Congress, President Trump would likely reject the bill. For the exact same reasons, the Congressional Review Act (“CRA”), which provides an opportunity for Congress to submit a joint resolution of disapproval of an agency’s rule, would likely not provide relief to House Democrats.

However, these limitations do not stop House Democrats from applying political pressure on the Trump administration. On November 29, 2018, House Energy and Commerce Ranking Member Frank Pallone, Jr., (D-NJ) and House Ways and Means Ranking Member Richard Neal (D-MA) sent a letter to the Trump administration requesting information on the October 24 guidance, as well as questioning the legality of this guidance.

Conclusion The Trump administration continues to use the regulatory process to curtail the impact of the ACA. The Trump administration’s guidance on Section 1332 State Innovation Waivers is the latest of a series of actions aimed to reduce regulatory constraints on states. Although this trend is being pursued with the goal of expanding more affordable plan options for consumers, many fear it will trim critical benefits and limit choices for those with greater-than-average health care needs, such as people with disabilities and chronic conditions. Given the makeup of Congress, House Democrats are limited in their ability to effectively reverse the Trump administration’s regulatory actions in this area.

7. CMS, FACT SHEET: State Empowerment and Relief Wavier Concepts (Nov. 29, 2018), https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/ Downloads/Waiver-Concepts-Fact-Sheet.pdf.

8. Id. 9. Id. 10. Id.

AMRPA Magazine / January 2019 13

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

14 AMRPA Magazine / January 2019

The Rest of the IRF-PAI

Lately, my articles have focused on topics ranging from process, impairment group and comorbidity coding, and FIM scoring to quality indicator coding for functional items.

This month heralds the rest of the IRF-PAI, which includes the Skin, Therapy Minutes, and Signatures sections.

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

One piece of good news regarding the 2018 IRF-PAI updates was that the information reported in the Skin section became streamlined as of October 1, 2018. Providers are now asked to report only the number of unhealed pressure ulcers/injuries present on admission and present on discharge. At discharge, the provider is also asked to note whether the pressure ulcer/injury was present on admission for stage 2, 3, 4 and unstageable pressure ulcers/injuries. This is significantly less data than was required in previous years, especially since we are no longer required to report the number of healed or worsening skin issues.

Over the years, CMS has provided a great deal of education on coding pressure ulcers/injuries. Some of the highlights include the definition of a pressure ulcer/injury, which is “a localized injury to the skin and/or underlying tissue usually over a bony prominence, because of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful.” The IRF-PAI training manual instructs you to code the skin conditions according to the definitions in the manual rather than using the National Pressure Ulcer Advisory Panel (NPUAP) guidelines because the NPUAP and IRF-PAI guidelines do not perfectly correlate. The coding of the skin section of the IRF-PAI should be conducted as close to admission as possible based on what was observed or palpated.

The manual is very clear about the fact that the initial findings should be coded on the IRF-PAI and the skin should be assessed as close to admission as possible. Code an ulcer/injury when the primary cause was pressure. Mucosal pressure ulcers are not staged, and should not be coded on the IRF-PAI. Surgical wounds should also not be reported on the IRF-PAI. If two or more pressure ulcers/injuries were observed at the time of admission and merge into one ulcer/injury, report the resulting ulcer/injury at the appropriate stage on the IRF-PAI. Several good examples of how to code pressure ulcers/injuries are in the IRF-PAI Training Manual. Review these examples if your team has difficulty coding this item.

The next section is Therapy Minutes, which are recorded at discharge. You are asked to code the number of minutes spent in Physical Therapy, Occupational Therapy and Speech Therapy during Weeks 1 and 2 of the patient’s stay. Remember that the day of the patient’s admission to the rehabilitation unit or hospital is the first day of the consecutive seven-day period for which you are recording therapy minutes. If

AMRPA Magazine / January 2019 15

the patient is in the hospital or unit for less than a full week, record the minutes amassed during the days they were there.

The breakdown of the modes of therapy include individual, concurrent, group, or co-treatment.

Individual therapy is therapy that is provided by one therapist to one patient. We record the time a patient spends in individual therapy using CPT codes that represent each 15-minute increment of time.

Co-treatment means that two therapists from different therapy disciplines are treating one patient together, with each therapist working on different activities to help the patient meet specific and differing goals. For billing purposes, each therapist captures their billable time using individual CPT codes such as therapeutic activity or gait training, but on the IRF-PAI co-treatment minutes should be recorded as all of the time that the individual therapists from each discipline spent with the patient.

The CPT code for group therapy is 97150 and it is defined as one therapist working with two-to-six patients at one time who are performing the same or similar activities. On the IRF-PAI, you should record all of the minutes that each patient spent in a group.

Concurrent treatment is a single therapist treating two patients at the same time and the patients are engaged in different activities.

From a coding perspective, it is important to capture the treatment of two patients by one therapist with the group therapy CPT code. On the IRF-PAI, you record all of the minutes that each patient spent in a concurrent session.

Too often I find that the treatment notes record minutes that do not match the total minutes reported on the IRF-PAI. Make sure that you are randomly auditing your IRF-PAI minutes against your documentation for accuracy and to identify why discrepancies occur. PPS coordinators should review the data entered on the therapy tab to make sure that the minutes add up to a minimum of 900 per week. If the numbers do not add up, bring this to the attention of the therapy manager. This is your first indication that some notes may be missing or the data pulled into the IRF-PAI is an incorrect representation of the care you provided.

Take note of what the IRF-PAI Training Manual now says about group therapy. They note that “the standard of care for IRF patients is individualized therapy. Group therapies serve as an adjunct to individual therapies. In those instances in which group therapy better meets the patient’s needs on a limited basis, the situation/ rationale that justifies group therapy should be specified in the patient’s medical record at the IRF.” This note indicates that not all treatment reported or counted in the patient’s three-hour rule tally must be individualized. Furthermore, it states that we should document differently to provide the reason we decided to treat the patient in a group setting.

16 AMRPA Magazine / January 2019

For counting minutes, remember that therapy evaluation minutes do count and should be recorded on the IRF-PAI. Therapy minutes recorded should only represent direct patient care time; family conference time, documentation time, unsupervised modalities, and significant rest periods are examples of time that would not be counted and recorded on the IRF-PAI. If the patient has an interrupted stay, the provider should still follow the seven-calendar day cycle when recording minutes. Do not move the days to exclude the days the patient was gone. Do not round minutes.

The therapy minutes reported should represent the actual time the therapist spent with a patient.

// I feel that PPS coordinators have one of the most difficult jobs in the industry, and they often receive little to no support simply because of the specificity of their duties.

The final section of the IRF-PAI is the signature page. Any staff member that has gathered information and completed the IRF-PAI should sign the signature page. Each time the IRF-PAI is updated, the person adding data should sign the IRF-PAI. At a minimum, there should be signatures to support the data entered for the admission IRF-PAI and for the discharge. Electronic signatures are allowed on the document, but they should be affixed in compliance with your state and local laws and in accordance with your policies.

Thus ends “the Year of the PPS Coordinator.” As I said in my first article, I feel that PPS coordinators have one of the most difficult jobs in the industry, and they often receive little to no support simply because of the specificity of their duties.

However, everyone in a unit or hospital depends on them to not only consistently do their job well, but to do so without ever expecting support from other members of the unit. This isn’t for a lack of wanting to help, but because there are rarely other staff members who have the skills required for the job. I truly hope that my articles this year have helped clarify some of the duties and responsibilities the PPS coordinators face so that they may be supported. At the very least, I hope they have a few more tools in their kit so their job is a little bit easier.

AMRPA Submits Comments to the Department of Health and Human Services on Patient Social Risk Factors Editor’s Note: On November 16, 2018, AMRPA submitted a comment letter to the Assistant Secretary for Planning and Evaluation (ASPE) at the Department of Health and Human Services in response to its request for information on how health care provider address beneficiaries social risk factors. The letter is reproduced below.

November 16, 2018 The Honorable Brenda Destro Acting Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services 200 Independence Avenue, SW Washington, DC 20201

Delivered electronically to: ASPEImpactStudy@hhs.gov Re: Request for Information on IMPACT ACT Research Study: Provider and health plan approaches to improve care for Medicare beneficiaries with social risk factors

Dear Assistant Secretary Destro: These comments are submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) with respect to the above captioned Request for Information.1 We welcome the opportunity to offer input to the Department of Health and Human Services (HHS) to inform its second report to Congress on the effect of socioeconomic status on quality and resource use measures as mandated by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. AMRPA supports the principles and objectives of the Act and remains committed to working with HHS and the Assistant Secretary for Planning and Evaluation (ASPE) to achieve them.

AMRPA is the national trade association representing more than 625 freestanding inpatient rehabilitation hospitals and rehabilitation units of general hospitals (collectively referred to as inpatient rehabilitation facilities (IRFs) by Medicare), outpatient rehabilitation service providers, long-term care hospitals (LTCHs), and several skilled nursing facilities (SNFs).

Inpatient rehabilitation hospitals and units (IRH/Us) provide hospital-level care, which is significantly different in intensity, capacity, and outcomes from post-acute care (PAC) provided in non-hospital settings. AMRPA members help their patients maximize their health, functional ability, independence, and participation in society so they are able to return to home, work, or an active retirement. The vast majority of our members are Medicare participating providers and, on average, Medicare Part A payments represent more than 60 percent of IRH/U revenues.2 In 2016, IRH/Us served approximately 350,000 Medicare beneficiaries, representing more than 391,000 stays.3 AMRPA’s responses to the questions posed in ASPE’s Request for Information follow below.

1. Are social risk data being used to target services or provide outreach? If so, how? How are beneficiaries with social risk factors identified? How is this data collected?

1. https://aspe.hhs.gov/system/files/pdf/259906/ImprovingCareMedicareBeneficiariesSocialRiskFactorsRFI.pdf 2. Medicare Payment Advisory Commission, Report to Congress, Medicare Payment Policy, 267 (Mar. 2018).

3. Id.

AMRPA Magazine / January 2019 17

IRH/Us use a multidisciplinary and comprehensive set of evaluative, diagnostic and therapeutic interventions focused on restoring functional capacity, activities of daily living and cognitive function. In fact, IRH/Us are required by CMS regulations to provide multiple disciplines of care, including physician, nursing, physical therapy, occupational therapy, speech and language therapy, and clinical social work, and to hold weekly interdisciplinary team meetings. The interdisciplinary team meeting allows members of the treatment team, which includes clinical social workers, to coordinate care and communication regarding the patient’s plan of care and treatment goals.

Interdisciplinary and coordinated care is essential to getting patients back to their homes and work sooner and gives them improved physical, social and emotional functioning and wellbeing.

Rehabilitation hospital care is patient-centric and accountable for each patient’s exposure to potential risk factors. Social risk factors are most certainly taken into account on a patientby-patient basis, especially as part of the discharge planning process. Discharge planning begins at – and ideally before – a patient admission to the IRH/U. The interdisciplinary team collaborates to evaluate the patient’s medical, social support, and financial support needs, and develops a discharge plan that addresses those needs accordingly. Specifically, a social work care management team meets with the patient and caregivers to conduct psychosocial and socioeconomic evaluations and to collect information about how social risk factors can influence an anticipated trajectory of care. This information is fed back to the clinical team at the interdisciplinary team conference to help inform the discharge planning process.

A person-centered approach means identifying the type of support and reasonable adjustments that enable each person’s needs to be met. The clinical social worker helps plan for longterm management of health care needs, including referrals to resources in the community to promote the highest level of independence. While this data may not be collected based on an industry-standardized platform, IRH/Us gather many data points and pay close attention to each patient’s unique situation and respond accordingly.

2. For patients with social risk factors, how does patients’ disability, functional status, or frailty affect the provision of services?

A patient’s disability, functional status, or frailty has a profound impact on the service they will need. The more severe a patient’s disability or impaired their functional status, the more challenging it can be for providers to ensure that the patient is receiving all the necessary care. Furthermore, the impact of socioeconomic status (SES) factors are oftentimes much more pronounced for lower-functioning patients who are likely to require multiple professional services after discharge; however, low SES individuals are less likely to be insured and are more likely to avoid medical care due to cost. 4

It is undeniably more challenging for certain patients to reenter the community following their IRH/U stay. As an example, some brain injury patients with cognitive impairments demonstrate risk-seeking behavior and might not have the adequate social resources (family or friends) to turn to for support. In instances where patients lack a social support network for a hospital to turn to, the hospital case worker recognizes that lifelong institutionalization may be a likely outcome for this patient.

Similarly, with regard to frailty, many older patients do not have living relatives nearby to turn to for caregiver support.

3. Are there especially promising strategies for improving care for patients with social risk?

Early identification of social risk factors enables IRH/Us to better prepare for potential services or supports that patients may additionally need after discharge from the rehabilitation hospital.

To do this, the IRH/U team is highly proactive in liaising and dialoguing with the referring hospital, oftentimes as part of the pre-admission assessment, to get key information such as the patient’s unique living situation, social support, geography and payer status.

When it comes to successful strategies, however, perhaps the most prominent are those providers use to minimize the negative impact of a patient’s lack of coverage when their payer does not cover downstream post-acute services, such as home health or skilled nursing care. To address the needs of these patients, IRH/ Us employ proactive and targeted strategies such as: Utilizing a paramedicine program to conduct home visits for patients who could not receive home health benefits. This type of program helps ensure that patients are progressing along their care trajectory as expected and can also help mitigate potentially preventable hospital readmissions.

Providing financial guidance services to help patients understand and navigate their benefits. In some instances, when a primary payer does not cover services such as skilled nursing care, IRH/Us will assist patients and their caregivers in applying for Medicaid to obtain coverage for these services after IRH/U discharge.

Providing financial assistance programs for underfunded patients.

Partnering with other providers along the care continuum to help defray the costs of certain services (e.g., sharing the cost of durable medical equipment or medications with the acute care hospital), and facilitating smooth downstream transitions of care (e.g., leveraging relationships with downstream providers to help an unfunded patient gain access to those services after IRH/U discharge).

Post-discharge, some IRH/Us also use “transition clinics” to provide a transitioning physician for patients being discharged who do not have a primary care physician overseeing their routine care.

4. Institute of Medicine, America’s uninsured crisis: consequences for health and health care. National Academies Press; 2009. p. 214.

18 AMRPA Magazine / January 2019

4. How are costs for targeting and providing those services evaluated? What are the additional costs to target services, such as case management, and to provide additional services (e.g., transportation)? What is the return on investment in improved outcomes or reduced healthcare costs?

Successful care management that facilitates a safe patient transition to the next site of care is a fundamental component of rehabilitation hospital care. The primary return on investment for providing case management and other services, such as those discussed above, are better outcomes as a result of helping patients access necessary post-acute services and transitioning them to the next setting in a timely manner. A post-stroke patient who is able to receive continuous rehabilitative services – from intensive therapy at the IRH/U to continuing to work with a therapist in home health – will achieve greater functional gains more quickly, and is less likely to need additional services in the long run. Hence, an investment in PAC in the shorter term will pay tremendous dividends in the long run. Facilitating transitions along the care continuum enhances efficiencies and reduces costs to the healthcare system overall (e.g., reduced lengths of stay).

There are also costs to the provider of investing in experienced social work staff resources, as described further below.

5. What are the best practices to refer beneficiaries to social service organizations that can address social risk factors?

Health care providers with demonstrated depth in social work resources are successful in connecting patients with local and regional social service organizations. In that regard, the clinical social workers seated within the interdisciplinary team at rehabilitation hospitals support the entire continuum of care by arranging and furnishing these unique services.

A rehabilitation hospital’s patients often come from a wide geographic area and beyond the hospital’s immediate market.

Accordingly, IRH/Us must develop and leverage partnerships with various entities throughout and beyond their market – including upstream referral sources and social service organizations – as those entities are more familiar with the local supports and resources within a patient’s community. IRH/Us also proactively reach out to social service organizations to develop relationships with resources in the community.

Indeed, it takes time and experience for a social work team to cultivate these relationships and it is an investment of a hospital’s staff resources. Some IRH/Us take a centralized approach by having a dedicated case worker assigned to patients who may be more challenging to discharge safely (and have a greater need for social services). These dedicated social workers have developed relationships with external partners to readily connect patients with community support services.

6. What lessons have been learned about providing care for patients with social risk factors?

Our members note that the unpredictability of engaging these patients has been an important lesson, as well as a challenge they continue to grapple with and adapt to. Sometimes, despite a hospital’s best efforts to develop a comprehensive patient-centric discharge plan and support the patient’s adherence to it, the patient and/or their caregivers do not follow through with the plan for reasons unknown to the hospital. There is also tremendous value in investing in external partnerships and relationships with other entities along the care continuum, and in staff resources within such as experienced social workers and case managers.

7. What are barriers to tailoring services to patients with social risk factors? How can barriers be overcome?

From our members’ perspective, the following factors can be significant barriers to developing services tailored for a patient’s unique care needs and situations: Payer source or funding: As described above, it is much more challenging for rehabilitation hospitals to ensure that un-/underfunded patients will be able to receive necessary post-discharge care. Hospitals undertake a variety of strategies to try to help patients overcome these barriers, such as offering paramedicine home visits or financial support services, as detailed above.

Caregiver presence/availability: The presence and willingness of family or community supports are critical drivers for IRH/Us when deciding upon a patient’s appropriate discharge destination. For example, even though a patient has met the goals of a rehabilitation hospital admission (e.g., regained household level ambulatory function and is able to walk on level surfaces at discharge), if he or she lives alone in a third floor walkup without handicap access, a discharge home may not be safe. Although a return to home or the community is the gold standard, it is not always the safest discharge setting. Even when the caregiver’s presence is expected at the outset, situations often change and families/caregivers’ involvement may shift as they come to appreciate the extent of support needed. To help mitigate this phenomenon, IRH/Us are proactive and engage caregivers throughout the patient stay to educate them on the anticipated post-discharge care needs.

Patient activation, engagement, and agency: An individual’s level of activation in managing their own health – patient activation model measure (PAM) – can determine the patient’s ability and motivation to “buy into” their care plan. This may vary according to age, education level, health literacy, motivation and illness. Providers aim to communicate health information in ways that are tailored and accessible to patients as one way of overcoming this barrier.

AMRPA Magazine / January 2019 19

Cultural factors: With regard to language barriers, IRH/ Us and health care providers have invested in translation technologies to facilitate their communication with diverse patient populations. In rehabilitation, there is even a greater need for having a live translator due to the highly dynamic nature of clinician-patient interactions in an intensive therapy session. IRH/Us help patients overcome language barriers by providing on-hand translators in therapy.

8. Which social risk factors are most important to capture?

To AMRPA members, some of the most important factors to capture are payer status, caregiver availability/presence, and geographic location.

9. Would standardized data elements for EHRs help you to collect social risk data? What do you see as promising future opportunities for improving data collection? For using existing or future data to tailor services?

As described above, IRH/Us collect information on social risk factors to inform the development of a patient-centered care plan, and specifically a discharge plan. The data collection process is already well integrated into a hospital’s clinical workflow and furthermore is likely to have been adapted to suit the needs of the hospital, community, or region. At this time, it is unclear how standardizing data collection in EHRs, in a global aggregate sense, could help providers improve upon how they collect and use this information for care planning purposes for individual patients.

There is a benefit to adjusting for social risk factors in Medicare payments and quality reporting programs. AMRPA strongly supports a methodologically sound approach to risk-adjustment for social risk factors, which we have recommended in the past.

Our members perceive dual-eligible status, low-income subsidy status, and geographic area of residence as important factors that are also more readily accessible in currently available data sources. In evaluating provider performance, CMS should compare quality performance and resource use for providers that have comparable proportions of similar patients, such as low-income beneficiaries. We also strongly encourage CMS

to develop a way to account for family/caregiver status and/or community supports. Research shows that beneficiaries who lack the adequate caregiver support have higher rates of readmission and lower rates of discharge to the community following PAC.5, 6 CMS should be cognizant of these factors as it continues to consider options to increase transparency in Medicare’s quality programs.

10. What are barriers to collecting data about social risk?

One barrier is resources – a hospital must have the adequate financial health to be able to invest in developing the depth of its social services bench. In addition, because IRH/Us oftentimes rely on the upstream referring hospital for this information, another common barrier is limited availability of pertinent information from the acute care hospital.

AMRPA appreciates the opportunity to provide input to the ASPE for a follow-up report to Congress on how providers serve beneficiaries with social risk factors. AMRPA is a strong supporter of the principles and objectives of the IMPACT Act, and remains committed to working with HHS to achieve the Act’s objective to enhance how socioeconomic status and social risk factors are accounted for in Medicare programs. If you have any questions, please contact Mimi Zhang, AMRPA Senior Policy and Research Analyst (mzhang@amrpa.org).

Sincerely,

Richard Kathrins, PhD Chair, AMRPA Board of Directors President and CEO, Bacharach Institute for Rehabilitation

Suzanne Kauserud, FACHE, MBA, PT Chair, AMRPA Quality Committee Vice President, Continuing Care Division - Inpatient Carolinas Rehabilitation / Atrium Health

5. Everink IH, van Haastregt JC, van Hoof SJ, Schols JM, Kempen GI. Factors influencing home discharge after inpatient rehabilitation of older patients: A systematic review. BMC Geriatrics 2016; 16: 5.

6.

Rodakowski J, Rocco PB, Ortiz M, et al. Caregiver integration during discharge planning for older adults to reduce resource use: a metaanalysis. J Am Geriatr Soc 2017; 65: 1748–1755

20 AMRPA Magazine / January 2019

CJR Evaluation Report Finds Significant Drop in Inpatient Rehabilitation Use and Hospital Concerns About Care Stinting

Mimi Zhang, AMRPA Senior Policy and Research Analyst

The Centers of Medicare and Medicaid Services (CMS) has issued its first evaluation report on the Comprehensive Care for Joint Replacement (CJR) model. Implemented in 2016 by the Centers for Medicare and Medicaid Services (CMS) Innovation Center, the CJR model holds acute care hospitals in certain markets accountable for the cost and quality of a 90-day bundle of elective and non-elective lower-extremity joint replacement (LEJR) episodes. CJR is unique as CMS’ only mandatory payment model to date, and it is a notable component of the agency’s strategy to shift from volume-based to value-based payment via alternative payment models (APMs).

This first annual report, prepared by the Lewin Group for CMS, presents early findings from the CJR model based on episodes in the first performance year (April through December 2016).

Highlights: »»

Data from the first nine months of CJR show that mandatory bundled payment lowered Medicare costs for hip and knee replacements.

»»

Cost savings come from shifting away from inpatient rehabilitation and skilled nursing to using lowerintensity PAC settings.

»»

Claims-based outcomes such as readmissions, mortality, and emergency department use were maintained in CJR; functional status outcomes not examined.

A key theme throughout the report – and thereby throughout CJR itself – is the significant reduction in the use of institutional post-acute care (PAC). Specifically, reductions in payments for both elective and non-elective LEJR episodes were “largely driven” by less use of inpatient rehabilitation hospitals and units (IRH/Us) and skilled nursing facilities (SNFs). This trend is not questioned by Lewin and, by extension, CMS. In fact, Lewin states that it “expect[s] such efforts…of shifting post-acute care to less expensive settings and reducing lengths of stay in institutional PAC provider settings.”

CJR participant hospitals, on the other hand, do not necessarily share in this embrace of shifting PAC dynamics. Interviewees Lewin spoke with for the report voiced their concerns about unintended consequences that CJR may wrought, such as premature hospital discharges, inappropriately attenuated PAC stays or inappropriate PAC placement, and misaligned incentives.

Background on CJR Model Design The CJR model requires participation for 731 acute care hospitals located in 67 metropolitan statistical areas (MSAs) around the country. In 2017 under the Trump administration, CMS scaled back the mandatory nature of the model so that, beginning in 2018 (performance year 3), only the 34 highest spending MSAs are required to finish out the remainder of the five-year demonstration. Hospitals in the 33 other MSAs were no longer required to participate but were given a one-time opportunity to continue.

Similarly, rural or low-volume hospitals in any of the 67 MSAs were also afforded the same flexibility.

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CJR holds participant hospitals financially accountable for the quality and cost of an episode of care, beginning with the LEJR surgery and extending through the 90 days after hospital discharge. All Medicare-covered items and services provided during the episode, with some exclusions, are included in the episodic cost bundle. All providers involved in the episode continue to be paid under Medicare’s existing fee-for service (FFS) payment systems.

At the beginning of each performance year, a 3 percent discount is applied to the blended historical payment amount. Through a reconciliation process after the end of each performance year, CMS assesses whether participant hospitals have met financial and quality targets. CMS uses a target pricing approach that incorporates historical hospital-specific and regional episode payments and a quality adjustment. CMS also stratifies elective versus non-elective fracture LEJRs into separate spending targets.

At reconciliation, CMS compares each hospital’s total episode payments for services provided during the clinical episode to its quality-adjusted target price. Hospitals that achieve both 1) LEJR episode payments below the target price and 2) a minimum quality score on the required quality measures will be eligible to earn a reconciliation payment from Medicare. Hence, the 3 percent discount can be reduced if the hospital’s actual quality performance is adequate. The quality composite score is based on hospital performance on the total hip arthroplasty/total knee arthroplasty complications measure, a Hospital Consumer Assessment of Healthcare Providers and Systems survey measure, and successful submission of patient-reported outcome data, which is a voluntary measure. The quality composite score is then used to categorize hospitals as “below acceptable,” “acceptable,” “good,” or “excellent” quality.

It is the mandatory participation that is a major distinction between the CJR model and previous CMS Innovation Center episode-based payment models, such as Model 2 of the Bundled Payments for Care Improvement (BPCI) initiative. For this evaluation, Lewin compared CJR episodes with a non-CJR control group of similar case mix and geography.

Impact of CJR Model: Key Takeaways Lewin found that CJR participant hospitals responded to the model by shifting patients to less expensive PAC settings and this was the main source of cost savings. The report’s key findings are summarized below.

The CJR model was associated with a statistically significant decrease in total payments for LEJR episodes. On average across all LEJR episodes, total Medicare payments were 3.3 percent ($910) lower for CJR episodes than for control group episodes. This was the case for both elective and fracture episodes, as well as episodes in MSAs with historically high or historically low average episode payments.

Total payments for elective CJR episodes were 3.6 percent ($880) lower and payments for LEJR fractures were 3.0 percent ($1,345) lower. Elective procedures accounted for 88 percent of total LEJR episode volume.

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Historically high-spending MSAs and low-spending MSAs achieved savings of 3.9 percent and 2.3 percent, respectively.

Institutional PAC payments were reduced by lowering utilization and by substituting less costly PAC for other PAC settings. While CJR derived some savings from reduced readmissions and Part B spending, savings were primarily due to shifting PAC to lower intensity settings. IRF/U and SNF payments decreased by $350 and $455, respectively.

Home health payments increased $86.

The average length of stay in an IRH/U or SNF decreased more for CJR patients than for control group patients.

Patients in the CJR model did not have significantly higher post-hospital readmission rates, emergency department visits, or mortality.

Despite concerns that CJR may lead to adverse patient selections issues, there was no indication that CJR participant hospitals selected healthier patients.

CJR participant hospitals reported that they chose to implement care redesign activities in response to the CJR model, including expanding patient education efforts, starting discharge planning earlier, developing preferred provider networks, and discharging patients to less expensive PAC settings.

Changes in PAC Utilization Under the CJR model, there was a shift from more intensive to less intensive PAC settings. For elective episodes, fewer patients were discharged to either an IRH/U or SNF, and those who did go to a SNF spent fewer days there. At the same time, there was a relative increase (4.4 percentage points) in the volume of elective LEJR patients being discharged to home health. See Exhibit 18.

Among fracture episodes, CJR participant hospitals appear to have substituted SNF for IRH/U care: there was a 3.3 relative increase in patients whose first PAC settings was SNF and a -3.6 relative decrease in those who went to an IRH/U. In fact, more than half of the savings for CJR fracture episodes was due to lower IRH/U payments, with IRH/U payments dropping 18.7 percent ($787) (see Table 1). Of note, this contrasts with what occurred in the control group over the same time frame, where IRH/U payments for LEJR fractures increased, from of $3,932 to $4,213 on average (see Exhibit 19). This observation suggest that utilization management practices regarding IRH/U care in CJR were considerably more aggressive.

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Table 1: Payments for LEJR Episodes Declined under the CJR Model Due to Reduced Institutional PAC Use, Q2 2016 – Q4 2016

Episode Type

Number of Episodes Estimated relative change in payments

Estimated relative change in utilization (percentage points)

All LEJR

Elective

Fracture

CJR

43,801

38,462

5,339

Control group

58,960

52,640

6,320

Total episode payments

-$910

-$880

-$1,345

SNF

-$455

-$461

-$73

IRH/U

-$350

-$273

-$787

HHA

$86

$85

$43

Part B

-$83

-$86

-$83

Readmissions

-$109

-$88

-$243

First PAC discharge: SNF

-0.5

-1.2

3.3

First PAC discharge: IRH/U

-2.2

-2.0

-3.6

First PAC discharge: HHA

3.9

4.4

0.5

Number of SNF days in 90-day episode

-2.0

-2.1

-1.6

Number of IRF days in 90-day episode

-0.1

0.1

-0.5

Source: The Lewin Group

Table 2: Claims-Based Quality Indicators Under the CJR Model

Episode Type

Number of Episodes Estimated relative change in quality of care (percentage points)

All LEJR

Elective

Fracture

CJR

43,851

38,511

5,340

Control group

59,561

53,209

6,352

Unplanned readmissions rate

0.0

0.0

-0.6

ED use

0.0

0.0

-0.3

All-cause mortality rate

0.1

0.1

0.4

-

0.0

-

Incidence of any complications Source: The Lewin Group

Quality of Care Lewin asserts that quality of care was maintained under CJR because there were no statistically significant changes in readmissions rates, emergency department visits and mortality (see Table 2). However, the quality indicators assessed were claims-based, and did not include any functional status measures or patient experience of care measures. Lewin says that evaluation reports in future years will examine functional status data from patient assessment instruments.

Providers Express Concerns The CJR hospitals interviewed by Lewin corroborated that they focused on changing PAC use and encouraged the use of less expensive PAC settings. Yet many interviewees also described concerns about potential negative quality and patient outcomes due to pressures to reduce Medicare costs.

24 AMRPA Magazine / January 2019

Interviewees enumerated numerous concerns, such as: CJR limited choices for patients and their doctors by encouraging shorter lengths of stay and the use of lower intensity PAC settings.

Providers were often under pressure to balance the needs of the patient with hospital clinical care pathways that were often stricter as a result of CJR. CJR’s financial incentives and pressures were ineffective and inappropriate methods of improving patient care.

CJR’ patient risk stratification by hospitals and surgeons could have undesirable consequences on higher risk patients. For instance, that while pre-surgical patient optimization may appropriately delay care for some less healthy patients, it could also result in some patients who were viewed as too risky not receiving surgery at all. [Lewin remarked that it did not observe patterns of adverse patient selection based on claims data.]

Traditionally underserved populations, such as those with low socioeconomic status or who were dually eligible for Medicare and Medicaid, are likely to be disproportionately impacted by CJR. CJR could have potential unintended effects for individuals who have substantial non-medical needs or substandard housing because it encourages earlier discharges home.

Their concern centered on patients who would be clinically ready for a discharge home but who lacked housing conducive to their recovery (e.g., ground floor access, bathroom grab bars) or a suitable caregiver to assist with functional needs. These patients could be at an increased risk for readmissions or additional medical costs.

Despite having only nine months of limited CJR data for this first report, Lewin and CMS appear eager to embrace the findings as “positive early results.” Furthermore, Lewin suggests that

a mandatory payment model such as CJR may “impel action” from health care providers that may not have acted otherwise to cut spending. Such a tone, taken in combination with HHS Secretary Alex Azar’s positive views towards mandatory payment models, might be harbingers of future mandatory APMs from this administration.

Lewin will continue to conduct annual evaluations of the CJR model. Future reports will include additional measures from patient surveys, reconciliation data, and patient assessments, which were not available in time to include in this report.

From a purely financial perspective, the CJR model has delivered on its goal of reducing the cost of LEJR care. But time will tell if it actually improves the value of care by providing high quality and durable functional outcomes, enhancing patients’ quality of life, and maintaining access to necessary post-acute care.

AMRPA Magazine / January 2019 25

CMS Expands MIPS to Therapists and Other New Clinicians in 2019 Final Rule

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

Highlights: »»

Weight of cost measures to increase

»»

Clinicians will have more flexibility to opt-in to program

On November 23, 2018, the Centers for Medicare and Medicaid Services (CMS) published the 2019 final rule for the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) in the Federal Register. This article summarizes finalized changes to the Merit-based Incentive Payment System (MIPS), which is one of two tracks under the QPP, with the other being participation in an Advanced Alternative Payment Model (AAPM). MIPS-eligible clinicians, (MECs) are evaluated across four performance categories: 1) Quality; 2) Cost (resource use); 3) Improvement Activities and 4) Promoting Interoperability, which was previously referred to as Advancing Care Information (ACI), and which replaces the EHR Incentive Program.

Background on MIPS MECs receive a total score between 0-100, which will result in a positive, neutral or negative payment adjustment for all PFS professional services rendered by that MEC. Each of the four categories is scored separately, weighted, converted to a numerical score, and then added to the MEC’s final score. Clinicians can also report as groups, either as an actual group practice or as a virtual group that comes together for purposes of reporting. Most of the same reporting requirements generally also apply to groups. In this article, both individual and groups of MECs will be referred to as “MECs.” MIPS generally uses a two year delayed payment system, so that services and scores achieved in CY 2019, referred to as “performance year 2019,” will be used to adjust payments for 2021, referred to as “payment year 2021.” In this article references to a year will refer to the performance year unless otherwise noted.

The MIPS payment adjustment began at a possible adjustment of plus-or-minus 4 percent of total payments for the first performance year (2017) increased to 5 percent for 2018, will increase to 7 percent in 2019 until leveling off at 9 percent in 2020 and thereafter. Originally, the MIPS payment adjustment was to apply to professional services and separately billed items, such as Part B drugs. However, the Bipartisan Budget Act of 2018 (BBA 2018) changed the program so that the adjustment is applicable only to professional services, and not separately billed items.

Addition of Therapists and Other New Clinician Types Currently, MECs are defined as physicians, physician assistants, nurse practitioners, clinical nurse specialists or certified registered nurse anesthetists. Beginning in 2019, CMS is statutorily permitted to include additional clinician types. In this year’s rule, CMS finalized several new clinician types for MIPS, including physical therapists (PTs), occupational therapists (OTs), speech-language pathologists (SLPs), audiologists, clinical psychologists and registered dietitians or nutrition professionals. Originally CMS has proposed to include clinical social workers, and

26 AMRPA Magazine / January 2019

exclude SLPs. However, due to changes made to available quality measures, CMS modified its proposal and finalized that SLPs and audiologists, along with registered dieticians, would be included, and clinical social workers would be excluded.

Hospital-based Outpatient Therapy Services Not Typically Included In response to the proposed rule, AMRPA sought clarification on how therapy services such as those provided by a PT and OT in the outpatient department of a hospital or another facility would be treated under MIPS. CMS responded by explaining in the final rule that it determines MIPS eligibility by using the unique combination of the Tax Identification Number (TIN) and rendering National Provider Identifier (NPI) of a specific, individual provider. Therefore, CMS states, if the claims submitted by a hospital or facility do not include the rendering NPI of the specific clinician performing the service, the claims will not be attributable for MIPS purposes. CMS also stated that it understands most hospital claims do not contain this information, and therefore the services provided in outpatient hospital settings, as well as clinicians who primarily practice there, will typically not be included in MIPS. AMRPA recommended that CMS find a way to include facility-based outpatient therapy services in MIPS, but CMS declined with little explanation.

AMRPA also urged CMS to take a more gradual approach to incorporating the new clinician types who will be included in the MIPS program due to the complicated processes and burden inherent in the program. AMRPA noted that physicians had much lower thresholds and reporting burdens when they began participating in the program. AMRPA laid out several recommendations, such as delaying incorporating these clinicians to give a full year’s notice, or creating an opt-in policy. CMS responded to AMRPA’s concerns by pointing out that MIPS is still in a “ramp up” process, and it will be several years before the program is fully implemented in terms of the full 9 percent payment adjustment and the weight given to certain measures, such as cost measures.

The only accommodation CMS provided for new clinician types is to weight the promoting interoperability category at zero percent of the total score for new clinician types that choose not to report those measures. This means that the

quality category for these clinician types would be weighted at 70 percent. Further, because there will be no cost measures attributable to therapists, they will also have their cost score reweighted to zero. Therefore, quality will make up 85 percent of therapists’ scores.

Low-Volume Threshold Exclusion Currently, a clinician is considered a MEC if they are one of the included clinician types, are not excluded due to participation under an AAPM, are not in their first year billing Medicare, and are not excluded due to low volume. The current lowvolume exclusion states that if an otherwise eligible clinician bills $90,000 or less in a professional services in year, or treats 200 or fewer Part-B Medicare patients in a year, he or she is excluded from MIPS. CMS proposed and finalized a third threshold, which would exclude any MEC that provides 200 or less covered professional services in a year. CMS’ finalized policy states that falling below any one of the three thresholds will exclude the provider from MIPs. While falling below any one of the three thresholds will exclude a provider from MIPS, CMS has proposed and finalized that any MEC who exceeds at least one of the low-volume thresholds can choose to opt-in to MIPS. Therefore, as an example, a clinician who billed less than 200 total beneficiaries, and billed less than $90,000 in Part B professional services could still choose to opt-in if they exceeded 200 total professional services for a year. Only those clinicians or groups that exceed all three of the thresholds will be required to participate in MIPS. The chart below breaks down the options for clinicians in relation to their volume of services.

The Four Performance Categories: Quality, Cost, Improvement and Interoperability As previously discussed, MECs are evaluated and scored under four categories: quality, promoting interoperability, cost and improvement activities. Under all categories except cost, MECs must submit data to CMS for scoring, unless exempted from that category. MECs earn a score for each category, and the final score is applied to a percentile which determines the payment adjustment. The table below breaks the finalized weighting of each category for 2019 (payment year 2021) and compares it to previous years’ weighting.

AMRPA Magazine / January 2019 27

Quality Performance Category: The quality category requires MECs to submit quality measures to CMS which are scored against a benchmark compiled for that measurement. There is a total possible score of 60 for quality measures, which is then applied to a total MIPS score. CMS proposed and then finalized weighting quality performance category at 45 percent of a MEC’s total score for 2019. This is a reduction from 50 percent for 2018. CMS also plans to gradually reduce the quality score by 5 percent per year until it reaches 30 percent. However, as previously noted, new clinician types such as physical and occupational therapists would have their quality score weighted at 85 percent due to the cost and promoting interoperability scores being reweighted to zero.

CMS will continue to impose a general reporting threshold (called the data completeness standard) that requires the MEC to submit measures on 60 percent of patients across all payers. However, some MECs may continue to use a CMS Web Interface or CAHPS measures for some of their measures, and for these the MEC must meet the applicable sample size specific to that measure.

MECs must continue to report at least six quality measures from CMS’ list of approved quality measures, including one measure that is designated as an outcome measure.

Alternatively, CMS has developed specialty sets, and a MEC can choose to report on the entire specialty set, even if the set has less than six measures, and satisfy the reporting requirements. Except for those clinicians considered facilitybased, as discussed below, CMS did not finalize changes to the number of measures that must be reported. Current quality measures can be explored on the CMS webpage.

CMS finalized a number additions to the general list of measures, and these changes can be found in Table A in Appendix 1 one of the final rule. CMS also modified a number of measures from specialty sets, which can be found in Table B in Appendix 1 of the final rule. Changes to the Physical Medicine Specialty set is found in Table B.14 in Appendix 1 of the final rule.

Quality scores are ultimately calculated against a benchmark of all measures of that type that are submitted. MECs receive a score of between 3 and 10 for all measures that meet the data completeness and case minimum threshold for that measure.

The quality performance category has a denominator of 60 total possible measure achievement points.

There are also several bonus points available in the quality category. MECs can earn two points for reporting a second outcome or patient experience measure. They can also earn one point for submitting other measures designated as “high priority” by CMS. CMS finalized in this rule that opioid-related measures would be deemed high-priority. Further, one bonus point is available for each measure submitted using electronic end-to-end reporting.

Finally, CMS has finalized that small practices of 15 MECs or less will receive six points added on to their final quality 28 AMRPA Magazine / January 2019

category score. Previously, CMS added five points to the total MIPS score, but finalized moving that bonus in to the quality category score for this year.

Promoting Interoperability Performance Category The promoting interoperability category encourages clinicians to utilize electronic health records and other electronic methods in their practices. MECs can earn up to 100 points based on the extent to which their practice incorporates certain objectives, which is then weighted into the final score.

This category was previously referred to as the “advancing care information” category.

By statute, CMS is required to weight the promoting interoperability category at 25 percent each year. However, there are many exceptions for this category that result in the score being reweighted to zero for eligible clinicians. For all of these exemptions, the clinician will have their score reweighted only if they do not report any measures in this category. If they do report measures, they will be assessed for their performance in the category with a weight of 25 percent.

CMS finalized that the following non-physician clinician types will be exempt from this category and have their scores reweighted to zero if they report no measures: physical therapists, occupational therapists, Nurse practitioner, physician assistant, clinical nurse specialist, certified registered nurse anesthetist, speech-language pathologists, audiologists, clinical psychologists and registered dietitians or nutrition professionals. In addition, small practices or practices without internet or other uncontrollable circumstances can claim a hardship exemption.

CMS also reweights this category for clinicians who are considered “hospital-based.” Hospital-based MECs are those who furnish 75 percent or more of their services at Point of Service (POS) Codes 21 (inpatient hospital), 22 (on-campus outpatient hospital) or 23 (emergency room). Despite AMRPA’s previous urging CMS has not included POS 61, which indicates the service is provided at an IRF and has also not included other post-acute care (PAC) settings, such as skilled nursing facilities (SNFs). This “hospital-based” definition is specific to the promoting interoperability category, and serves a separate purpose than the “Facility-based” definition discussed more fully below.

When a clinician has their promoting interoperability score reweighted to zero, the 25 percent will be reassigned to the quality category. For those that also have their cost scores reweighted to zero, which is many non-physician clinicians, their quality score will be weighted at 85 percent of their total MIPS score.

For scoring, CMS previously used a base, performance and bonus score system, where MECs could earn a base score of 50 percent for using 2014 edition certified EHR technology (CEHRT), and then earn additional points for further activity.

CMS has finalized a significant revision to this system for 2019 and will instead base the promoting interoperability score on five required measures across four objectives: e-Prescribing,

Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Each measure will vary in weight for a total score of 100. In 2019, measure scoring will be performance based meaning that a score is awarded based on the number of patients for whom the measure is successfully completed.

CMS finalized that to earn any points, MECs need to be using 2015 CEHRT (2014 CEHRT would no longer be permitted).

In addition, MECs must report data on all measures and perform a security risk analysis to earn any points, meaning failure to report on any measure results in a score of zero for the entire category. CMS finalized keeping the promoting interoperability performance period at 90 consecutive days during the performance year, meaning that clinicians need only meet the standards for a 90-day period of their choosing during calendar year 2019.

In addition to continuing to use the two existing cost measures, CMS finalized the addition of eight episode-based cost measures in 2019. These measures are displayed in the table below.

As shown, CMS categorizes these proposed measures into two types: Procedural type and acute inpatient medical condition type. For procedural measures, the episode will be attributed to the MEC who furnished the trigger service. For the acute inpatient medical condition measures, the measure will be attributed to any MEC that delivers 30 percent or more of the Evaluation and Management (E/M) services during the triggering hospitalization. All measures are scored on a scale of 1-10. The MEC’s score is based on a comparison to the same specialty as that MEC. All of the measures that are applicable to a MEC are weighted equally towards the MEC’s cost performance score.

Cost Performance Category In broad terms, the cost performance category evaluates MECs on the costs associated with their patients’ care when compared to peers. The cost information comes to CMS via Medicare contractors who process claims. The cost score is converted in to a final numeric input towards the MEC’s total MIPS score.

Currently, CMS weights cost at 10 percent of the total score. In this rule, CMS finalized that cost will be weighted at 15 percent for 2019, and the agency plans to further increase the weight by 5 percent each year until it reaches 30 percent in 2022. The increased weight will be taken from corresponding decreases to the quality category, which will decrease by 5 percent per year.

It is important to note that cost measures cannot be attributable to many non-physician clinicians that do not render services that trigger attribution for these cost measures, such as therapists.

Therefore, many non-physician clinician types will have this score reweighted to zero.

Improvement Activities Category Under the improvement activities category, MECs must attest to completing certain activities that earn points based on their weight as either medium (10 points) or high (20 points).

Performance on improvement activities is not measured, so MECs do not need to achieve any particular results, but rather must just attest to the activities’ completion. As directed by statute, CMS weighs improvement activities at 15 percent of the total score each year.

All current and proposed cost measures are calculated through data submitted to Medicare contractors as part of claims, so no additional reporting is required of MECs. Currently, cost performance is determined by two metrics: the Total Per Capital Cost measure, and the Medicare Spending Per Beneficiary (MSPB) measure. The cost performance category performance period is the entire calendar year of the performance year, so cost will be measured based on all Part B Medicare patients treated during the entire calendar year of the performance year.

CMS finalized adding six new activities to the current list of activities, modified five of the existing activities, and removed one of the activities it deems redundant. A list of the activities available in the Improvement Activities Inventory Appendix 2 of the final rule. Finally, CMS finalized a repeal of its previous policy that certain improvement activities qualify for a bonus under the promoting interoperability category if they involve the use of EHR.

As with last year, there are 40 points total available for improvement activities. MECs will again be able to earn points by selecting from any combination of high-weighted activities (20 points) or medium-weighted activities (10 points). The minimum performance period for improvement activities is a continuous 90-day period, so all activities must be performed for at least 90 days.

AMRPA Magazine / January 2019 29

Facility-Based Scoring In last year’s final rule, CMS established a policy that would allow clinicians it defines as “facility-based” to have the option to use their facility’s Hospital Value Based Purchasing (VBP) Program scores as a total substitute for the MIPS quality performance and cost performance scores, beginning in 2019.

For MECs that qualify as facility-based, there are no reporting requirements under the quality and cost performance categories. The VBP score for the MEC’s affiliated hospital is translated to the quality and cost score for the MEC using a percentile calculation. CMS finalized that there will be no opt-in for the facility-based option. However, if a facility-based MEC chooses to submit quality measures, CMS will use those quality measures for scoring purposes if it will result in a higher score for the MEC, but otherwise will use the VBP score.

Under CMS’ original policy set to begin in 2019, to qualify as a facility-based MEC and eligible to use a facility’s VBP score, a MEC must furnish 75 percent or more of services at POS codes 21 (inpatient hospital) or 23 (emergency room).

AMRPA responded to this policy last year by urging CMS to also allow Inpatient Rehabilitation Facility (IRF)-based clinicians to use their hospitals’ IRF Quality Reporting Program (QRP) score to substitute for the cost and quality measures.

CMS responded that because the Hospital VBP program is a pay-for-performance, as opposed to the IRF QRP’s pay-forreporting structure, it was appropriate to use the Hospital VBP but not the IRF QRP for MIPS purposes. Therefore, CMS did not include IRF-based clinicians (POS code 61) in the definition of facility-based, and also did not allow for the IRF QRP to substitute for the cost and quality performance measures.

In this year’s final rule, CMS has finalized several changes to the facility-based option for 2019. First, CMS has added the POS code for on-campus outpatient hospital (POS code 22) to the list of codes it will count towards the facility-based definition. Therefore, any MEC that bills 75 percent or more of services at POS code 22 (or a combination of 21, 22 and 23) will also be considered facility-based. One caveat CMS has included is that the clinician must bill at least one service at POS 21 or POS 23 to qualify for facility-based scoring. CMS also sought comment in this year’s proposed rule, in response

30 AMRPA Magazine / January 2019

to stakeholder feedback like AMRPA’s, on how it could best incorporate post-acute care (PAC) facility-based clinicians in to the facility-based scoring. However, it did not change its final policy to include any PAC facility-based providers, and said it will take comments into consideration for future rulemakings.

Complex Patients CMS proposed and finalized that it will continue to apply a 5 point bonus called the Complex Patient Bonus, which will be added on to the final, total MIPS score. This bonus is based on the Hierarchical Condition Category (HCC) of patients treated, which is used to evaluate risk in Medicare Advantage plans and other programs, as a proxy for medical complexity.

CMS will also factor in percentage of patients treated by the clinician who are dual-eligible for Medicare and Medicaid to account for this bonus. CMS says it will continue to use the complex patient bonus until it develops more targeted ways of evaluating and compensating for patient risk and complexity.

Performance Thresholds MIPS has a “performance threshold” that is the score a MEC must achieve to avoid a negative payment adjustment and achieve earn a neutral or positive adjustment. For 2018, the threshold was set at 15 points out of the 100 possible points. For 2019, CMS has raised the threshold to 30 points.

In addition to the standard performance threshold, there is also an exceptional performance threshold. CMS has a pool of $500 million, on top of the MIPS payment adjustment, to give to exceptional performers under MIPS. In 2018, CMS set the exceptional performance threshold at 70, and has finalized that it will raise this threshold to 80 for 2019.

CMS Estimates of MIPS Payment Adjustments Based on its final policies, CMS estimates that for 2019, 91.2 percent of MIPS eligible clinicians that successfully submit data to MIPS are expected to receive positive or neutral payment adjustments. This figure excludes clinicians who are expected to receive a negative payment adjustment as a result of failing to report MIPS data. CMS further estimates that 58 percent will receive a positive adjustment along with an exceptional performance payment adjustment. CMS has broken down the estimated payment adjustments by practice size in the chart below.

2019 Physician Fee Schedule Final Rule Removes Functional Reporting for Therapists, Changes Outpatient Physician Billing and Documentation Requirements

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

Highlight: »»

Outpatient Therapy functional reporting requirements removed effective January 1, 2019.

»»

Outpatient physician visit changes to be phased in over several years.

On November 23, the Centers for Medicare and Medicaid Services (CMS) published the Physician Fee Schedule and Quality Payment Program (QPP) Final Rule for calendar year (CY) 2019 in the Federal Register. This article summarizes changes to the Physician Fee Schedule (PFS); a separate article in this issue summarizes changes to the QPP. The PFS sets payment rates for professional services and items not included in facility payments, such as outpatient therapy services and physician visits. For 2019, CMS finalized many notable proposals, including creating new payment modifiers to distinguish outpatient therapy services provided in full or part by a therapy assistant, the removal of functional reporting requirements for outpatient therapy services, and lowering documentation burden for outpatient physician Evaluation and Management (E/M) services. CMS also finalized with modifications its proposal to consolidate payment levels for outpatient E/M visits.

// For 2019, CMS finalized many notable proposals, including creating new payment modifiers to distinguish outpatient therapy services provided in full or part by a therapy assistant...

Repeal of Functional Reporting Requirements for Outpatient Therapy Since January 1, 2013, all providers of outpatient therapy services, including physical therapy (PT) and occupational therapy (OT) have been required to include functional status information on claims for therapy services. This functional reporting requirement mandated that therapists include HCPCS codes G8978 through G8999 and G9158 through G9186 (“G-codes”) to describe a patient’s functional limitation and severity at the time of the initial service, periodic progress intervals, at discharge and when reporting

AMRPA Magazine / January 2019 31

certain evaluative and re-evaluative procedures. Therapists were also required to document functional reporting information in the patient’s medical record each time it was reported.

minutes of 45 minutes of services, and the code being billed is in 15 minute increments, only one of the units must reflect the modifier.

Through this rulemaking, CMS proposed and now finalized elimination of the functional reporting requirements for outpatient therapy services, effective January 1, 2019. CMS says in response to requests from stakeholders seeking burden reduction, because the data was originally intended to inform future changes to the outpatient therapy caps, which have now been repealed, and because it had not found the data particularly insightful, it no longer believes it necessary to continue collecting the data.

Therefore, and as AMRPA recommended, it has finalized the elimination of the requirement that therapists include G-codes and appropriate modifiers in claims for outpatient therapy services beginning January 1, 2019.

Physician Evaluation and Management (E/M) Visits Coding and Payment Changes CMS finalized significant changes to the Evaluation and Management (E/M) codes used by physicians and advanced practice clinicians (APCs) to bill office and other outpatient visits (CPT Codes 99201-99205 & 99211-99215). Currently, a physician or an APC (referenced hereinafter jointly as “practitioners”) will bill one of five E/M codes for outpatient visits. There are currently two distinct set of the five codes for outpatient visits: one for new patients (99201-99205) and one for established patients (9921199215).

Payment Reduction and New Modifiers for Therapy Assistants The Balanced Budget Act of 2018, which repealed the therapy caps also instituted a reduced payment rate of 85 percent of the otherwise applicable payment for any therapy services provided “in whole or in part” by a therapy assistant. The new payment rate will take effect on January 1, 2022, but the Act requires CMS to develop a modifier for services provided in whole or part by a physical or occupational therapy assistant by January 1, 2019, and also mandates the modifier begin to be used by January 1, 2020.

Currently, there are three modifiers – GP, GO and GN – used to distinguish therapy services provided under a PT, OT or speechlanguage pathology (SLP) plan of care, respectively. The GP (for PT) and GO (for OT) modifiers currently are defined to also include when a therapy assistant participates in the delivery of the therapeutic services. In order to distinguish therapy services delivered entirely by a therapist from services provided with the participation of a therapy assistant, CMS finalized a policy that will require that a payment modifier be applied to claims when services are delivered in whole or in part by a physical or occupational therapy assistant. These modifiers will be used in addition to the currently used modifiers (GP or GO). CMS finalized modifier CQ to indicate a PT assistant provided the services in whole or in part, and CO when an OT assistant provided the services in whole or in part.

CMS also adopted a definition for when a service will be considered delivered “in part” by a therapy assistant. CMS originally proposed that whenever the therapy assistant is involved in any minute of the therapeutic portion of the service, the claim must be billed with the new therapy assistant modifier. However, in response to feedback, including AMRPA’s comment letter, CMS revised its position on when a service would be considered delivered “in part” by a therapy assistant. CMS has now defined “in part” to mean any involvement beyond a de minimis portion of the service. CMS further explained de minimis to mean up to 10 percent of the minutes of a billed service.

The agency also acknowledged that it will need to further explain how this standard will be applied in fluid clinical situations, and it plans to do so in its 2019 rulemaking cycle. In the final rule, CMS also clarified that the modifier only need to be applied per applicable unit, so if a therapy assistant is only involved in 15 32 AMRPA Magazine / January 2019

Practitioners determine which level of visit to bill based on guidelines from the American Medical Association (AMA). The AMA guidelines instruct physicians to choose one of the five levels based on three factors, including history of present illness (HPI), physical examination and medical decision making (MDM). The level of code generally increases as time, resources or the complexity of the patient increases, with level 1 being the lowest and level 5 being the highest. There are unique payments for each of the 10 codes, and payment increases as the level of the visit increases.

CMS has finalized a significant consolidation of E/M payment rates for outpatient visits, effective January 1, 2021. In conjunction with this change, it also finalized new add-on codes for primary care services, non-procedural specialty care, and extended time visits, which will provide additional payments. CMS provides a specialtyby-specialty breakdown of the expected payment changes on page 59650 of the final rule, using 2019 values. Final 2021 rates will be calculated with updated data.

CMS proposed to consolidate payment levels 2-5 of the current outpatient E/M codes, so that any level above level 1 receives the same payment amount. CMS said that consolidating the payments for these visits would allow it to loosen documentation requirements, as discussed more fully below, and not have to perform audits of compliance with billing appropriate visit levels.

In response to stakeholder comments, including feedback from AMRPA, CMS adopted a modified version of its proposal in this final rule. Specifically, it will only consolidate visit levels 2-4, and will leave level 5 visits as a separate, distinct payment. CMS says it modified its proposal because it agreed with comments like those provided by AMRPA that reducing level 5 payments could jeopardize access to care for the most vulnerable and complex patients. The new payment rates will be effective 2021, which CMS says will allow it to continue to seek industry feedback for any further necessary changes to this policy.

As it originally proposed to do for visit levels 2-5, CMS will determine the consolidated payment rate for visit levels 2-4 by using a weighted average of the frequency in which the visit levels were billed using the last five years of Medicare claims data. The chart below demonstrates the changes from current payment rates for E/M visits to the projected payments for 2021 under this finalized policy.

New E/M Visit Payment Rates Visit Level New Patient

Established Patient

Current Payment

Estimated Updated Payment

2

$76

$130

3

$110

4

$167

5

$211

$212

2

$45

$90

3

$74

4

$109

5

$148

$149

New E/M Add-on Codes and Payments Effective 2021 In order to account for E/M visits that may be either over- or undercompensated based on the consolidation of visit levels 2-4, as well as to address existing shortcomings in the code system, CMS proposed and now finalized a number of new add-on codes that provide additional payments on top of the baseline E/M payment rate, effective 2021. The chart below estimates the additional payments that will be provided by these add-on codes and compares them to current baseline E/M payment rates.

CMS proposed and finalized G-code GPC1X, which would be used to indicate that the E/M visit was part of care that is considered primary care in nature. CMS says it would expect practitioners to add this code when serving in the primary care role for a patient.

The add-on code may also be used for both new and established patients, but only for E/M levels 2-4.

CMS states it is not limiting the code to specific disciplines or circumstances, but expects that the documentation in the medical record would support that the services being provided were primary care in nature. Beginning on page 59641 of the final rule, CMS provides several examples of clinical circumstances in which a specialist may be serving in a primary care role and would appropriately use this add-on code.

CMS has also proposed and now finalized a new add-on code

that it says should be used when practitioners furnish complex, non-procedural specialty care. In the proposed rule, CMS said it identified a number of specialties that provide non-procedural specialty care and typically bill at levels 4 and 5, and would permit those specialists to use this add on code when billing levels 2-5 by including those specialty types in the code descriptor.

In the final rule, CMS modified its final policy to permit the code to be used on only E/M visit levels 2-4, rather than levels 2-5, to conform to its other modifications. CMS also added a number of specialists to the list in the code descriptor (provided below) that were not in the original proposal, including psychiatry, infectious disease and pulmonology. However, CMS also stated in this final rule that there may be specialists enrolled in Medicare under other specialties that can nonetheless use the add-on codes when clinical circumstances warrant. As with the primary care add-on code, the non-procedural specialty code may be used for both new and established patients, and will be available beginning in 2021.

GCH0X Code Descriptor: Visit complexity inherent to evaluation and management associated with nonprocedural specialty care including endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, interventional pain management, cardiology, nephrology, infectious disease, psychiatry, and pulmonology (Add-on code, list separately in addition to level 2 through 4 office/outpatient evaluation and management visit, new or established).

CMS has also finalized a new G-code (GPRO1) for prolonged services when the E/M service requires an extended amount of time. This code may be used as an add-on for visit levels 2-4 when the visit takes between 34-69 minutes for established payments and 38-89 minutes for new patients, effective 2021. CMS says that to use this code practitioners will need to note that the requisite number of minutes were spent with the patient, but do not need to document specifically why the extra time was medically necessary.

CMS also states that given its parallel change to allow time to be used as the sole factor in determining visit level (as discussed more fully below) any visits that exceed the threshold of 69 or 89 minutes (for established and new patients, respectively) could be billed as

New E/M Visit Payment Rates with Add-On Codes

New Patient

Established Patient

Visit Level

Current Payment

Estimated Updated Payment

With Primary Care or Specialty Add-on Code*

With Extended Services Add-on Code

2

$76

$130

$143

$197

3

$110

4

$167

5

$211

$212

Not Available

Not Available

$90

$103

$157

$149

Not Available

Not Available

2

$45

3

$74

4

$109

5

$148

AMRPA Magazine / January 2019 33

a level 5 visit with the currently existing CPT add on code 99354 for extended services.

Modified Guidelines and Documentation Requirements for E/M Visit Levels Beginning 2021 CMS has finalized that beginning in 2021, practitioners may use two additional options for determining which level E/M visit to bill in lieu of the current AMA guidelines. The first option is to rely solely on the MDM aspect of the guidelines to determine which level to bill, and not factor in HPI and exam. Under this choice of criteria, the practitioner will only need to have documentation matching the MDM aspect of the visit in order to clear an audit for the claim.

The second new option being provided for practitioners is for them to choose the level of the visit based solely on the time involved in the visit. Under this option, CMS would require the practitioner to document the general medical necessity of the claim and also the total time spent on the patient. The amount of time that must be spent is the official typical time provided with corresponding CPT code.

CMS also makes clear that even when these new options become available in 2021, practitioners may continue to use the current guidelines that include all three criteria (HPI, MDM and exam) when determining which visit level to use. Further, CMS says it expects clinicians to continue to use all five of the E/M visit codes in an appropriate manner, despite there being no payment differential between levels 2-4.

CMS has also finalized that it will require only level 2 documentation for visit levels 2-4. This new policy is applicable when a practitioner chooses to use the current guidelines, or to rely on the newly finalized MDM option to determine visit level.

For visit levels determined by time, practitioners will need to document the medical necessity of the visit and the amount of time spent on the visit.

For level 5 visits, the practitioner must continue to use current level 5 guidelines, or may provide just level 5 documentation for MDM. A practitioner providing a level 5 visit may also document solely based on time, if the they document the medical necessity of the visit and that they spent at least the typical time currently associated with that code (40 minutes for established patient and 60 minutes for new patients).

34 AMRPA Magazine / January 2019

CMS continues to expect practitioners to code the appropriate E/M code based on the visit level (as determined by the modified guidelines discussed above) but practitioners no longer have to document beyond what is required of level 2 visits. CMS says it expects many practitioners will continue to provide documentation beyond level 2 requirements as it may be necessary for quality, continuity of care or legal purposes.

Removing Redundancy in E/M Visit Documentation Effective 2019 In addition to the other changes to E/M visit levels and documentation, CMS has removed some documentation requirements for all E/M visit levels, effective 2019. Specifically, CMS will now require that for established patients, practitioners will be only required to focus documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history. CMS says it continues to expect that practitioners would conduct clinically relevant and medically necessary elements of history and physical exam; however practitioners will not need to re-record elements if there is evidence that the practitioner reviewed and updated the previous information.

CMS also finalized for 2019 that for both new and established patients, practitioners will no longer be required to re-enter information in the medical record regarding the chief complaint and history that are already entered by ancillary staff or the beneficiary. The practitioner will be permitted to indicate in the medical record that they reviewed and verified this information without repeating it. CMS states that these policy changes are optional, and a practitioner could choose to continue to provide more detailed information.

Finally, CMS also finalized a proposal to lessen the documentation needed for teaching physicians. Currently, a teaching physician must personally document their role and participation in the E/M service in the medical record. Effective 2019, any physician, resident, or nurse can note in the medical record that the teaching physician was present at the time of service delivery.

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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

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AMRPA Magazine / January 2019 35

HHS Report on Electronic Health Record Adoption and Interoperability Among SNFs and HHAs

Highlights: »»

More HHAs (78 percent) adopted EHRs than SNFs (66 percent) in 2017.

»»

Like other health care settings, HHAs and SNFs also experience challenges in integrating information received electronically from outside sources.

»»

HHAs (32 percent) and SNFs (37 percent) most commonly used EHRs to exchange health information over other methods.

»»

Nearly 40 percent of HHAs used telehealth technology to keep track of patients’ health between in-person visits.

The Department of Health and Human Services (HHS) Office of the National Coordinator for Health Information Technology (ONC) recently published a data brief that describes the state of health IT use among skilled nursing facilities (SNFs) and home health agencies (HHAs) in 2017. Specifically, it presents key measures on electronic health record (EHR) adoption and interoperability from nationally representative surveys of SNFs and HHAs. The brief also describes variation in interoperability by method of electronic exchange and examines the extent to which these post-acute care (PAC) settings have information electronically available at the point of care.

Interoperability has the potential to improve care transitions among between acute care, post-acute care and other providers of care. Poor communication and coordination during these transitions may lead to adverse events including readmissions and medication errors. ONC reports that majority of SNFs and HHAs have adopted EHRs; however, EHR adoption rates were higher among HHAs than SNFs. Among HHAs with an EHR, a majority used their EHRs for both reconciling and recording medications.

HHAs were also more likely to engage in the use of these functions compared to SNFs. Unlike hospitals and office-based physicians, PAC providers (inpatient rehabilitation hospitals, long-term care hospitals, SNFs, HHAs) are not eligible to participate in the Medicare and Medicaid Promoting Interoperability Programs, formerly known as the Medicare and Medicaid EHR (or Meaningful Use) Incentive Programs.

HHAs and SNFs differed in their rates of engaging in the four interoperability domains: sending, receiving, finding and integrating health information received from outside sources. HHAs are more likely than SNFs to engage in each domain of interoperability.

Over half of HHA electronically sent or received health information; compared to 41 percent of SNFs. However, both HHAs and SNFs had lower rates of electronically finding and integrating patient health data. Only 18 percent of SNFs report that they integrate patient health information electronically received from outside sources. Like HHAs and SNFs, hospitals have a similar pattern related to interoperability; while many are electronically sending and receiving health information, fewer possess the capability to electronically find or integrate data from external sources.

Having patient health information electronically available from outside sources varied by the methods HHAs and SNFs used to exchange information. An EHR was the most common method used to exchange information for both facility types. Yet, at least 43 percent of HHAs and 29 percent of SNFs used more than one method for electronic exchange of health information. Facilities that used multiple methods of electronic exchange, were more likely to engage in the four interoperability domains. These

36 AMRPA Magazine / January 2019

facilities were also more likely to have information electronically available at the point of care. For example, SNFs that use an EHR, Health Information Organization (HIO), and read-only access are twice as likely to have information available at the point of care; compared to SNFs that use an EHR alone. Although using multiple methods increases the availability of information, it also may increase the complexity and cost of data exchange.

ONC reports that HHAs also need to use technology during in home patient visits and to monitor patients between visits. Threefourths of HHAs (72 percent) used mobile technology. Among HHAs that used this technology, 85 percent used it during patient visits to directly enter data into their EHR. About four in 10 HHAs (37 percent) used telehealth. There was no variation in the use of telehealth technology by HHAs ownership status (private vs. not) or location (urban vs. rural).

Nearly half of HHAs (55 percent) and SNFs (48 percent) had information available from outside providers at the point of care.

Among facilities with an EHR, a majority of HHAs and SNFs used their EHR for medication management purposes.

Figure 2. Percent of SNFs and HHAs with an EHR that used medication management functions, 2017.

Key Findings EHR adoption rates were higher among HHAs compared to SNFs. In 2017, over three-quarters of HHAs and two-thirds of SNFs reported they had adopted EHRs. HHAs are more likely than SNFs to engage in each domain of interoperability.

Figure 3. Percent of SNFs and HHAs with an EHR that reported having the ability to electronically send, receive, find, and integrate patient health information, and have outside information available, 2017.

SOURCE: 2017 IQVIA Nursing Home, n=1,000 and 2017 IQVIA Home Health Agency, n=1,004. Notes: * Difference is statistically significant at p<0.05. The denominator includes HHAs and SNFs that adopted an EHR.

HHAs had higher rates of recording and reconciling patient medications using an EHR compared to SNFs. Almost all HHAs used their EHRs to record patient medications and reconcile medications.

Almost 9 out of 10 SNFs with an EHR recorded patient medications using an EHR. About one-third of HHAs and SNFs relied on EHRs alone to electronically exchange patient health information.

Table 1. Percent of HHAs and SNFs that used different methods of electronic exchange (EHR alone, health information organization (HIO), and read only access, 2017.

SOURCE: 2017 IQVIA Nursing Home, n=1,000 and 2017 IQVIA Home Health Agency, n=1,004 Census. Notes: * Difference is statistically significant at p<0.05.

About half of HHAs engaged in electronically sending or receiving patient health information from outside providers; compared to four out of 10 SNFs. Integration of received information lagged behind other interoperability domains for both HHAs and SNFs. More HHAs (41 percent) had the ability to find patient’s health information from outside facilities than SNFs (27 percent).

HHAs were twice as likely to integrate patient health information than SNFs.

SOURCE: 2017 IQVIA Nursing Home, n=1,000 and 2017 IQVIA Home Health Agency, n=1,004. Notes: * Difference is statistically significant between HHAs and SNFs at p<0.05. Read Only is defined as permission to access files or directories where the user is only allowed to read not make changes.

About 43 percent of HHAs and 29 percent of SNFs used more than one method for electronic exchange.

Nearly one-third of SNFs did not use an EHR, HIO, or readonly access to an EHR for electronic exchange of patient health information.

AMRPA Magazine / January 2019 37

A greater proportion of HHAs (20 percent) used all three methods of electronic exchange (EHR and HIO and readonly access) than SNFs (eight percent).

Nearly one-fifth of HHAs (19 percent) and SNFs (17 percent) exchanged data using an EHR and read-only access.

Neither HHAs nor SNFs used both HIO and read-only access for electronic exchange.

SNFs that used EHRs, HIOs, and read-only access were twice as likely to have clinical information from outside organizations electronically available than SNFs that only used an EHR.

Almost three out of four HHAs used mobile technology during patient visits.

Among HHAs that use mobile technology during visits, most (85 percent) used devices to enter information directly into their EHR system.

About 4 out of 10 HHAs used telehealth technology to keep track of patients’ health between in-person visits.

Figure 5. Rates of telehealth technology use among HHAs by ownership type and location (rural vs. urban).

Table 2. Interoperability domains (send, receive, find, integrate) by methods of exchange for HHAs and SNFs.

SOURCE: 2017 IQVIA Home Health Agency, n=1,004.

Notes: Telehealth includes video conferencing or remote patient monitoring devices that collect data such as vital signs or blood sugar levels and transmit the data back to the agency. *Difference is statistically signigicant at p<0.05.

SOURCE: 2017 IQVIA Nursing Home, n=1,000 and 2017 IQVIA Home Health Agency, n=1,004.

Among HHAs that use an EHR, HIO, and read-only access, almost all facilities (94 percent) had the ability to query for patients’ health information from outside facilities.

Using EHR, HIO, and read-only access enabled eight out 10 SNFs to routinely send and receive information with outside organizations.

HHAs using all three methods of electronic exchange had higher rates of reporting electronic availability of patient health information at the point of care compared to those that used only an EHR.

38 AMRPA Magazine / January 2019

The use of telehealth technology did not vary by HHAs’ ownership status and location. Almost 40 percent of HHAs used telehealth for tracking patients’ health across each of these categories.

For the complete report please see: Citation Henry, J., Plypchuck, Y., & Patel, V. (November 2018) Electronic Health Record Adoption and Interoperability among U.S. Skilled Nursing Facilities in 2017. ONC Data Brief, no. 41. Office of the National Coordinator for Health Information Technology: Washington, DC.

AMRPA Magazine / January 2019 39

Functional Status Data Improves Identification of High-Cost Cases in Comprehensive Care for Joint Replacement Highlight: »»

Incorporating functional status data in CJR risk adjustment improves the identification of high-cost episodes among patients undergoing lowerextremity joint replacements.

A recent research study published by Health Services Research evaluated the ability of claims-based risk adjustment and clinical data to identify 90-day episode costs among lower extremity joint replacement (LEJR) patients according to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) program provisions. The CJR program is a mandatory bundled payment model for lower-extremity joint replacement (LEJR) procedures implemented in select markets around the country.

// The CJR program is a mandatory bundled payment model for lowerextremity joint replacement (LEJR) procedures implemented in select markets around the country.

Bundled payment programs without appropriate risk adjustment could lead to adverse selection among patients requiring LEJR because the target episode prices may be below total actual costs. Hence the authors sought to investigate whether other risk adjustment approaches such as the CMSHierarchical Condition Category (CMS-HCC) or including patient-level factors could better predict high-cost 90-day LEJR episodes. These episodes are most potentially most affected by risk adjustment. Currently, the CJR program only limits price stratification to hip fracture, Medicare Severity-Diagnosis Related Group (MS-DRG), and geographic region. It does not take a patient’s functional status into account.

Methods The study included Medicare fee-for-service (FFS) data for qualifying CJR episodes in the United States, and FFS data linked with clinical data from CJR-qualifying LEJR episodes performed at High Value Healthcare Collaborative (HVHC) and Mayo Clinic in 2013. There were three populations: a) all 363,621 CMS patients with a qualifying LEJR procedure; b) 4,881 patients treated at any High Value Healthcare Collaborative (HVHC) member organization; and c) 918 patients at the Mayo Clinic population.

HVHC and Mayo Clinic populations are subsets of the total FFS population to assess the additive value of additional pieces of clinical data in correctly assigning patients to cost groups. The clinical data was taken from participating health care systems

40 AMRPA Magazine / January 2019

merged with Medicare FFS data. The researchers collected functional status information based on a measure of patient’s ability to climb two flights of stairs among the Mayo Clinic population. Among this population, 20.6 percent reported the inability to climb two flights of stairs, 37.7 percent reported that they could climb two flights of stairs with difficulty, and 24.0 percent reported that they could climb two flights of stairs with no difficulty.

Results When modeling per CJR specifications, the authors observed low to moderate model performance (CMS C-Stat=0.714; HVHC C‐Stat=0.628; Mayo C-Stat=0.587). Adding CMS Hierarchical Condition Category (HCC) improved identification of patients in the top 20 percent of episode costs (CMS C‐Stat=0.758, HVHC C Stat=0.692, Mayo C-Stat=0.677). Additionally incorporating clinical variables, particularly functional status in the population for which this was available (Mayo C-Stat=0.783), improved ability to identify patients within cost groups.

When patient-level factors were modeled against 90-day episode costs, factors associated with high-cost episodes were the youngest and oldest age groups (< 65 years; ≥80 years),

dual eligibility status, having a hip or “other” procedure (i.e., complications of orthopedic device, fractures or degeneration of the lower extremity) versus a knee or ankle procedure, and residence in an urban or rural setting. Within the HVHC and Mayo Clinic subpopulations, the researchers found that inability to climb two flights of stairs was associated with high-cost episodes. If patients were able to climb two flights of stairs prior to surgery, they are less likely to be in the highest cost episodes. Unmarried status was also associated with higher cost compared to married or having a life partner.

The authors concluded that policy makers could use these findings to improve payment adjustments for bundled LEJR procedures. The data suggest that CMS should use more granular risk adjustment methods in CJR and include functional status data to develop benchmark LEJR episode costs that are more representative of actual patient costs.

For the research article, see Identifying high-cost episodes in lower extremity joint replacement, Health Services Research, November 5, 2018.

AMRPA Magazine / January 2019 41

Study Analyzes Variation in Community Discharge Rates After Inpatient Rehabilitation

Highlights: »»

The overall rate of successful community discharge after inpatient rehabilitation was 63.7 percent.

»»

216 performed significantly better than the mean national rate and 203 performed significantly worse.

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 mandated a quality measure of successful community discharge for post-acute care services and examining variation in performance nationally could help identify opportunities for improving patient-centered quality of care. To meet this mandate, the Centers for Medicare and Medicaid Services (CMS) added the Discharge to Community-PostAcute Care measure to the Inpatient Rehabilitation Facility Quality Reporting Program in fiscal year (FY) 2017.

A recent study published in JAMA Network Open examined facility-level and geographic variation in rates of community discharges (as defined by the CMS measure) after inpatient rehabilitation among fee-for-service (FFS) Medicare beneficiaries. While the study was designed to mimic CMS’ specifications and risk adjustors for the Discharge to Community-IRF QRP measure, it did not examine providers’ performance rates on the actual IRF QRP measure.

// 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.

The study authors followed CMS’ measure specifications to identify the cohort, define the outcome and calculate risk-standardized facility and state rates.

The study included 487,862 Medicare fee-for-service beneficiaries discharged from 1,154 inpatient rehabilitation hospitals and units’ (IRH/Us) from December 31, 2013, through October 1, 2015. As defined by the Medicare measure, a patient is successfully

42 AMRPA Magazine / January 2019

discharged to the community if they are discharged to selfcare or home health and remain there without experiencing an unplanned rehospitalization or die within the following 31 days.

Results The overall rate of successful community discharge after inpatient rehabilitation was 63.7 percent (95 percent CI, 63.6 percent-63.8 percent). Risk-standardized rates ranged from 42.9 percent to 83.6 percent across IRH/Us (higher rates are better). The rates were lowest in the Northeast (Massachusetts, 55.9 percent; New Hampshire, 57.0 percent) and highest in the West (Oregon, 70.3 percent; Hawaii, 73.3 percent). Among the 487,862 patients included in the study, mean (SD) age was 76.4 (10.8) years, and 56.9 percent were female. Two-hundred sixteen IRH/Us (18.7 percent) performed significantly better than the mean national rate and 203 (17.6 percent) performed

significantly worse. Risk-standardized state rates ranged from 55.9 percent to 73.3 percent.

The authors concluded that the observed variation suggests that there are opportunities that exist for improving performance on this quality measure. Achieving better functional outcomes may contribute to higher community discharge rates because better motor functional outcomes were observed among higher performing facilities. They recommend future research to identify the aspects of care delivery and the community services and supports that facilitate successful community discharge.

For the complete study, see: Facility and Geographic Variation in Rates of Successful Community Discharge After Inpatient Rehabilitation Among Medicare Fee-for-Service Beneficiaries, JAMA Network Open. November 9, 2018;1(7):e184332.

AMRPA Magazine / January 2019 43

Medication-Related Adverse Events and Non-Elective Readmission in Acute Ischemic Stroke

Highlights: 

Inpatients who experienced medication-related adverse events during their acute care hospitalization had significantly greater odds of being readmitted within 30â&#x20AC;&#x2030;days post-discharge.

Data is limited on the effects of medication-related adverse events occurring during hospitalizations for stroke. A study published in BMC Neurology sought to characterize reasons for acute readmission after acute ischemic stroke (AIS) and determine if medication-related adverse events occurring during AIS hospitalization were associated with 30-day readmission post-discharge. Secondary objectives examined whether demographic, clinical and hospital characteristics were associated with post-AIS readmission.

// Inpatient records were screened for diagnostic and external causes of injury codes indicative of medication-related adverse events, including adverse effects of prescribed drugs, unintentional overdosing and medication errors.

The study used the Nationwide Readmission Database to identify index AIS hospitalizations in the United States between January and November 2014.

Inpatient records were screened for diagnostic and external causes of injury codes indicative of medication-related adverse events, including adverse effects of prescribed drugs, unintentional overdosing and medication errors.

Nationally representative estimates of AIS hospitalizations, medication-related adverse events, and acute non-elective readmissions were computed using survey weighting methods. Adjusted odds of readmission for medication-related adverse events and select characteristics were estimated using unconditional logistic regression.

Of 439,682 individuals hospitalized with AIS in 2014, 4.7 percent experienced a medication-related adverse event. Overall, 10.7 percent of hospitalized individuals

44 AMRPA Magazine / January 2019

with AIS were readmitted within 30 days of discharge. The authors state that reasons for readmission were consistent with those observed among older adults. Patients who experienced a medication-related adverse event had a greatly increased likelihood of being readmitted within 30 days (adjusted odds ratio (AOR): 1.22; 95 percent CI: 1.14-1.30). Several factors were identified as being associated with all-cause 30-day readmission, including but not limited to being younger than 40 years (AOR, 1.12; 95 percent CI: 1.00-1.26), Medicare insurance coverage (AOR, 1.33; 95 percent CI: 1.26-1.40), inpatient stays greater than one week (AOR, 1.38; 95 percent CI: 1.33-1.42), having seven or more comorbidities (AOR, 2.20; 95 percent CI: 2.08-2.34), and receiving care at a for-profit hospital (AOR, 1.20; 95 percent CI: 1.12-1.29).

The study concluded that medication-related adverse events were positively associated with 30-day readmission for non-AIS causes and that future studies are needed to determine whether medication-related adverse events and readmissions in AIS are avoidable.

For the study, see, Association between medication-related adverse events and non-elective readmission in acute ischemic stroke, BMC Neurology. 2018 Nov 19;18(1):192.

AMRPA Magazine / January 2019 45

Study Examines Patients Dissatisfaction with Hospital-to-SNF Care Transitions

Highlights: 

Interventions are needed to improve transitions from hospital to SNF that include focus on patients and families.

A recent study published in the Journal of General Internal Medicine related the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs).

To better understand care transitions, the researchers conducted semi-structured interviews with staff from hospitals and SNFs, and with SNF patients and their families. The interviews focused on all aspects of the discharge planning and SNF placement processes including who is involved, how decisions are made, patients' experiences, hospitalSNF communication, and the presence of programs to improve the transition process.

Study participants included 138 staff in 16 hospitals and 25 SNFs in eight markets across the country, and 98 newly admitted, previously communitydwelling SNF patients and/or their family members in five of those markets.

Interviews were qualitatively analyzed to identify overarching themes.

// Study participants included 138 staff in 16 hospitals and 25 SNFs in eight markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/ or their family members in five of those markets.

The study found that patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication

46 AMRPA Magazine / January 2019

reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown.

are associated with medication errors and unnecessary rehospitalizations. The authors recommend interventions that include a focus on patients and families to improve transitions from hospitals to SNFs.

The study authors concluded that there are problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members for post-discharge care. Previous research suggests that problematic or hurried transitions from hospital to SNF

For the study abstract, see Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility, Journal of General Internal Medicine, 2018 Oct 18.

AMRPA Magazine / January 2019 47

Traumatic Brain Injury Readmission Rates and Reasons in a Rural Population

Highlights: 

There is a significant rate of readmissions in the year after a diagnosis of TBI.

Readmissions after a traumatic brain injury (TBI) have significant impact on long-term patient outcomes through interruption of rehabilitation. A study published in the Trauma Surgery Acute Care Open examined readmissions in a rural population. Previous research has shown that TBIs occur at a higher incidence and are associated with a higher mortality rate in rural populations compared with urban/ metropolitan areas.

// The study found that TBI readmission rates in a predominantly rural-based population was 22 percent during the year following the injury.

The study included discharge data on all patients 15 years and older who were admitted to an Arkansas-based hospital for TBI and obtained from the Arkansas Hospital Discharge Data System from 2010 to 2014. The data set includes diagnoses, age, gender and inpatient costs. The Hospital Cost and Utilization Project (HCUP), Clinical Classification Software (CCS) and Chronic Condition Indicator (CCI) were used to identify chronic disease and body systems affected in principal diagnosis.

The study found that TBI readmission rates in a predominantly rural-based population was 22 percent during the year following the injury. Of the 3,114 cases of significant head trauma, more than two-thirds were attributed to fall injuries, with motor vehicle crashes accounting for 20 percent of the remainder. The mean length of stay (LOS) of the initial hospitalization was 6.5 days and 691 of these patients were readmitted to an Arkansas hospital within the following year, totaling 1,368 readmissions. Of the readmissions, 16.4 percent of patients were admitted for altered mental status, 12.9 percent with shortness of breath (SOB), and 9.4 percent with chest pain. Mental disorders (psychosis, dementia and depression) and organic nervous symptoms

48 AMRPA Magazine / January 2019

(Alzheimer's disease, encephalopathy and epilepsy) were the primary source of readmissions. More than one-third of the patients were admitted in the following year for chronic diseases such as heart failure (8.6 percent), psychosis (5.2 percent), and cerebral artery occlusion (4.1 percent). Potential cardiovascular issues accounted for the second highest reason for readmission.

The mean age of readmitted patients was 71.1 years and most readmitted patients were older than 70.

chronic diseases are among the most reported reasons for readmission in this time period, demonstrating the effect severe head trauma has on long-term treatment.

For the study, see Defining severe traumatic brain injury readmission rates and reasons in a rural state, Trauma Surgery Acute Care Open. 2018 Sep 8;3(1):e000186.

The study showed that there is a significant rate of readmissions in the year after a diagnosis of TBI. Complications with existing

AMRPA Magazine / January 2019 49

Latest Research Findings

Inpatient Rehabilitation Quality of Care from the Patient's Perspective The Archives of Physical Medicine and Rehabilitation published results of a study of neurological rehabilitation inpatients who reported their experience of care and pain status at discharge and one-month after discharge. The aim was to compare, by collection time and patient characteristics, the premise of using patientreported data for inpatient rehabilitation quality measures.

The cohort study comprised 391 patients with neurologic conditions across two inpatient rehabilitation hospitals (IRHs). The authors calculated 18 quality measure scores using participants' responses to 55 experience of care and health status questions addressing communication, support and encouragement, care coordination, discharge information, goals, new medications, responsiveness of staff, cleanliness, quietness, pain management, care transitions, overall hospital rating, willingness to recommend, and pain.

Of the 391 participants reporting at discharge, 277 (71 percent) also reported post-discharge after multiple attempts by email, mail and telephone. Five of the 16 experience of care quality scores increased significantly between discharge and post-discharge.

The percentage of participants reporting high pain levels at discharge did not change across time periods. Patients with less education, older age, higher motor and cognitive function, and those who were non-Hispanic Black had more favorable quality measure scores. The experience of care quality scores at discharge ranged from 25 percent (responsiveness of hospital staff) to 75 percent (willingness to recommend hospital); corresponding postdischarge scores were 32 percent to 87 percent, respectively.

The authors found that patients' responses to an experience of survey tended to be more favorable after discharge compared

50 AMRPA Magazine / January 2019

to discharge, suggesting that survey timing is important factor when it comes to collecting experience of care data. In addition, patient responses were more favorable for patients with certain characteristics, which supports the need for risk adjustment if patient-reported quality measure scores are compared across inpatient rehabilitation providers.

For the study, see Inpatient Rehabilitation Quality of Care from the Patient's Perspective: Impact of Data Collection Timing and Patient Characteristics, Archives of Physical Medicine and Rehabilitation, 2018 Nov 23.

Impact of a Bundled Payment Model on Revision Total Joint Arthroplasty Patients A study published in the Journal of Arthroplasty evaluated the impact of care redesign on the quality of care in a bundled payment model for primary total joint arthroplasty (TJA).

Compared to primary TJA, revision TJA is more technically challenging and is also associated with increased readmissions, complications, and expense. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients.

The authors compared quality metrics for all revision TJA patients including readmission rate, use of post-acute care (PAC) facility after discharge, length of stay (LOS) and cost, between the year leading up to the bundled payment redesign and the two years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison.

The study found that despite a volume increase of 37 percent over the study period, readmissions declined from 8.9 percent to 5.8 percent. Use of PAC facilities decreased from 42 percent to 24 percent and LOS decreased from 4.84 to 3.92 days. The cost of the hospital episode declined by 5 percent.

The authors state that instituting a bundled payment resulted in lower readmission rates for revision TJA patients, though the impact was not as pronounced as in the primary TJA population.

The authors attributed the positive changes to an altered institutional mindset, resulting from an invested and aligned care team, with active physician oversight over the care episode.

For the study, see Bundled Payment "Creep": Institutional Redesign for Primary Arthroplasty Positively Affects Revision Arthroplasty, Journal of Arthroplasty. 2018 Oct 29.

AMRPA Magazine / January 2019 51

Study Recommends Frequent Monitoring of Bladder Changes and Complications over the First Year After Inpatient Rehabilitation A study published in the Spinal Cord Series and Cases examined changes in bladder management and development of bladderrelated complications in the first year after discharge from inpatient spinal cord injury (SCI) rehabilitation. The study sought to determine whether urinary tract infection (UTI) is associated with bladder management technique or severity of SCI during this time period.

Study methods included a post hoc analysis of bladder-specific responses to a phone intervention meant to reduce secondary complications of paralysis in adults (nâ&#x20AC;&#x2030;=â&#x20AC;&#x2030;169) over the first year after discharge from initial inpatient rehabilitation. The study found that bladder management was associated with injury level during and immediately after inpatient rehabilitation, and with American Spinal Injury Association (ASIA) Impairment Scale (AIS) score over the entire year.

During the first year following discharge, approximately one in five patients changed the bladder management technique and urinary incontinence occurred in a substantial proportion of those performing intermittent catheterization (IC). Specifically, among participants performing intermittent catheterization IC, 20 percent had urinary incontinence weekly or more frequently.

The cumulative incidence of UTI was 71 percent by the end of the study, and between 27 and 46 percent of subjects reported UTIs during each three-month period. Subjects with spontaneous voiding reported significantly fewer UTIs than those using IC or indwelling catheterization (IDC), but there was no significant difference in UTIs between IC and IDC.

52 AMRPA Magazine / January 2019

The study findings suggest a need for more frequent monitoring of bladder changes and complications over the first year after IR. For the study, see Urinary tract infections and bladder management over the first year after discharge from inpatient rehabilitation, Spinal Cord Series and Cases. 2018 Oct 19;4:92.

House and Senate 1st Session 116th Congressional Calendar:

Days for State and DistrictSession Work Periods House and Senate 1st 116th Date Note House Senate Congressional Calendar: January 1 New Year’s Day X X 7 X Days January for421-State and District Periods January - 25 Martin Luther King Jr. Day Work X X

February 18 - 22 Presidents’ Day X March 18 - 22 X DATE NOTE HOUSE April 15 - 26 Spring Holiday X January 1 New Year’s Day X May 27 - 31 Memorial Day X January 4 - 7 July 1 - 5 - Independence Day X Summer X X January 21 - 25 July 29 – August 30 Martin Luther King Holiday Jr. Day August 5 – August 30 Summer Holiday February 18 - 22 Presidents’ Day X September 2 - 6 Labor Day X March 18 - 22 September 30 - October - 11 Rosh Hashanah &Yom Kippur X X Columbus Day X X April 15 - 26 October 14 Spring Holiday November 4 - 8 X May 27 - 31 Memorial Day X November 11 Veterans Day X July 1 - 5 Day November 25 - 29 Independence Thanksgiving Break X X December 16 - 31 Summer Holiday Winter Holiday X X July 29 – August 30 X = State/District Working Period

X X SENATE X X X X X X X X X X X X

X X X X X X

August 5 – August 30

Summer Holiday

X

September 2 - 6

Labor Day

X

X

September 30 - October 11

Rosh Hashanah &Yom Kippur

X

X

October 14

Columbus Day

X

X

November 4 - 8

-

X

November 11

Veterans Day

X

X

November 25 - 29

Thanksgiving Break

X

X

December 16 - 31

Winter Holiday

X

X

X = State/District Working Period

AMRPA Magazine / January 2019 53

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Visit eRehabData.com to learn more, or contact Sam Fleming at sam@erehabdata.com to receive a free demo. Without losing any historical data, our staff help you migrate to the only patient assessment system that is trusted, owned, used, and supported by the medical rehabilitation industry.

56 AMRPA Magazine / January 2019