AMRPA Magazine July 2018 by AMRPA

July 2018 â&#x20AC;¢ Vol. 21, No. 7

AMRPA Addresses Ways of Cutting the

RED TAPE

July 2018 • Vol. 21, No. 7

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

Table of Contents Letter from the Chair

Legislative Update

Large Coalition of Rehabilitation Stakeholders Sends Strong Signal to CMS that Bundling Must Measure Patient Function/Satisfaction

Understanding the 60% Rule and Tracking Your Compliance

CMS Proposes to Reinstate the Home Health Pre-Claim Review Demonstration

Mimi Zhang AMPRA Senior Policy and Research Analyst

Kaiser Family Foundation: Affordable Care Act’s Insurance Marketplaces Continue to Stabilize

Patricia Sullivan AMRPA Senior Editor

Medicare Trustees: Part A Trust Fund to be Bankrupt by 2026

AMRPA Responds To Call for Public Comment on the Transfer of Health Information

AMRPA Submits Comments to CMS’ Innovation Center on the Implementation of BPCI Advanced

AHRQ’s Scorecard Shows Decline in Hospital-Acquired Conditions

GAO Conducts Review of Veterans Choice Program, Finds Improvements are Needed to Address Access Challenges

Study Examines Health Insurance and Disparities in Mortality Among Older Survivors of Critical Illness

Comprehensive Care Physician Model Improves Care, Lowers Hospitalization, Study Finds

Latest Research Findings

John Ferraro, MS AMRPA Executive Manager Carolyn Zollar, MA, JD AMRPA Executive Vice President for Government Relations and Policy Development

Lovelyn Robinson AMRPA Researcher and Editor Brian McGowan and Shirley Soda AMRPA Design and Layout

AMRPA Magazine, Volume 21, Number 7 AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA). AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Individuals who are employees of member institutions may subscribe to the magazine for $100 annually. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color. Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Samantha Schwarz, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1132, Email: sschwarz@amrpa.org Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content ©2018 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Kellen Company. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 750, Washington, DC 20045

AMRPA Magazine / July 2018

Letter from the Chair

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

AMRPA Addresses Ways of Cutting the Red Tape Recently I had the honor of participating in a roundtable discussion on postacute health care hosted by the House Ways and Means Health Subcommittee and chaired by Rep. Peter Roskam (R-IL). This roundtable focused on what steps Congress could take to cut red tape in the Medicare program. The discussion was a chance for the members of the subcommittee to hear from representatives of the post-acute care field including inpatient rehabilitation hospitals and units (IRH/Us), long-term care acute care hospitals, skilled nursing facilities, home health agencies, hospice, and beneficiary advocate groups. Joining me at the round table to discuss rehabilitation was Justin Hunter from Encompass Health. In the discussion, we noted that the 60% Rule was increasingly being misconstrued as a proxy for medical necessity by contractors or private payors. The arbitrary nature of the rule has been compounded by the fact that the 13 conditions were based on care observed during the 1970s, when treatment for excluded conditions such as cardiac events, organ failure and cancer were limited or nonexistent. The rule simply has not kept pace with the evolution in medicine. We noted that the Center for Medicare and Medicaid Services (CMS) could reduce the compliance threshold to a percentage less than 60% and also has the ability to add new diagnoses beyond the original ones chosen more than three decades ago.

// This roundtable focused on what steps Congress could take to cut red tape in the Medicare program

The three hour rule, the other onerous regulation for rehabilitation hospitals and units, was also discussed. We explained that a labyrinth of sub-regulatory guidance, other policies and Medicare contractor decisions have made it difficult to comply with this rule. Relaxing both of these two policies is well within CMSâ&#x20AC;&#x2122; authority and could materially minimize the administrative burdens on IRH/Us. Relaxing these rules, we argued, would in no way compromise the critical care that inpatient rehabilitation patients receive. We also asked for more transparency from CMS. As examples, we urged the agency to convene recurring open door rehabilitation forums and establish a post-acute advisory council. Hosting such forums would be an easy way to facilitate greater understanding of Medicare policies among IRH/U providers and arm CMS with greater insight and understanding of the medical rehabilitation field. The final issue addressed the annual Medicare payment rule for rehabilitation hospitals. We expressed concerns about establishing a new case-mix and patient classification system for rehabilitation hospitals and units proposed to start in FY 2020. This new system would utilize clinical data that inpatient rehabilitation providers began collecting pursuant to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act last fiscal year. Implementing this new system would be premature because too little is known about the data behind it and it would be inconsistent with the timeline established in the IMPACT Act for post-acute care payment reforms. The forum was well received by all in attendance and opened the door to explore ways to reduce regulatory burden and for inpatient rehabilitation providers to shift more resources to patient care.

AMRPA Magazine / July 2018

FAIR FUND Fund for Access to Inpatient Rehabilitation

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LEARN MORE & JOIN TODAY www.thefairfund.org We are the Fund for Access to Inpatient Rehabilitation, a Common Legal Defense Fund Composed of Americaâ&#x20AC;&#x2122;s Top Inpatient Rehabilitation Hospitals and Units. Fighting Restrictive Medicare Policies â&#x20AC;˘ Challenging Aggressive Contractors We need all IRFs to lend a hand in challenging aggressive Medicare auditors in order to level the playing field, and preserve and enhance patient access to IRF care. For more information, or to speak with a FAIR Fund leader or staff member, contact Rebecca Schnorf at rschnorf@firminc.com or at (217) 321-2477. 4

AMRPA Magazine / July 2018

Legislative Update

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

Highlights: »»

The Trump administration’s Justice Department has launched a new level of assault on the pre-existing condition exclusion protections of the ACA.

»»

Senate Republicans are filling out a four-page checklist to rank dozens of bills that Leadership could take up in the coming months. The list includes proposals related to the employer mandate, health savings accounts, association health plans, short-term limited-duration insurance, and other Affordable Care Act-related measures.

»»

CMS requests public comments on revival of previously failed pre-claim review demonstration for home health.

»»

President Trump announces his pick for a new Veterans Affairs (VA) Secretary – Acting Secretary Robert Wilkie.

»»

President signs veteran’s health overhaul, which consolidates the VA’s community care programs, into law.

»»

Senate Majority Leader Mitch McConnell (R-KY) announced that he is cancelling the August recess to allow Senators to pass appropriations bills and make progress on the President’s nominees.

ACA Again on Chopping Block As we go to print, the Trump administration’s assault on the Affordable Care Act (ACA) continues, with the Justice Department’s filing a brief indicating it will not defend the ACA against the legal challenge to its constitutionality brought by 20 Republican-led states. Immediately before the brief’s filing, three Justice career attorneys withdrew from the case, likely reflecting angst with the historic breaking of Executive Branch and Justice Department’s longstanding practice and tradition of defending upholding existing statutes. Given Congressional failure to repeal fundamental core provisions of the ACA last summer, this Justice decision creates instability and renders a potentially large blow to individual insurance market protections and signifies Trump administration intent to seek continued erosion of ACA protections. Conservatives Eye Renewed ACA Repeal Effort Recent reports indicate that a group, consisting of conservative think tanks and Republican lawmakers, is set to release a new health reform proposal in June as part of a renewed effort to repeal the Affordable Care Act (ACA). Among its provisions, the plan is expected to block ACA grant funding to states, end the law’s Medicaid expansion and expand health savings accounts. It builds on legislation developed by Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA) that failed to pass the Senate last year. While some Republicans, including Sen. Ron Johnson (R-WI), have already expressed support for the proposal, Majority Leader Mitch McConnell (R-KY) stated that he would return to the issue only if it were clear that the GOP had the votes to pass a repeal bill. In addition, some members have expressed concern that a renewed repeal fight could be a liability for Republicans heading into the midterm elections. Speculation over ACA repeal comes even as Virginia’s Republican-led legislature voted to expand Medicaid last week. Though the White House opposed the expansion, state lawmakers acknowledge that the administration’s support for work requirements helped to win over Republicans in the State Senate and House of Delegates. On a related front, President Trump recently highlighted the administration’s health insurance reform initiatives. Speaking at a signing ceremony for “right-to-try” legislation (S. 204) to expand access for critically ill patients to treatments under development, the president indicated that new regulations are forthcoming to encourage the use of association health plans (AHP) and to expand access to short-term, limited-duration (STLD) insurance. The Labor Department released a proposed rule on AHPs in January, and the Department of Health and Human Services issued a proposed rule in February to increase the maximum duration of STLD coverage.

AMRPA Magazine / July 2018

Appropriation Season Rolls Along with a First Minibus With Fiscal Year (FY) 2019 appropriations activity ramping up, the House passed a “minibus” package combining the Energy-Water, Military Construction-VA, and Legislative Branch spending measures on June 9. These are among the least controversial of the appropriations bills. Senate Majority Leader Mitch McConnell (R-KY) has also discussed the possibility of packaging additional bills into similar minibuses. The Senate is scheduled to mark up its FY 2019 Labor-HHS Appropriations bill the week of June 25. It is unclear when the House will take up its version. The House also passed a $14.7 billion “rescissions” package (HR 3) on a 210-206 party-line vote on June 7, with Democrats unified in opposition. Initially, President Trump had proposed $15.2 billion in spending cuts, but on May 8 reduced the cuts by $515 million in response to Republican lawmakers' concerns. The revised package does maintain the proposed $7 billion in cuts to Children’s Health Insurance Program (CHIP) funds. Its path is unclear in the Senate. Although Senate Republicans can pass the measure with a simple majority under a 1974 Budget law, the votes in support are uncertain in that chamber. The House Begins Opioid Week and Aims to Pass Several Measures As we go to press, the House expects to begin consideration of opioid legislation the week of June 11. This comes after Committees of Jurisdiction have successfully considered several measures to address the opioid epidemic. On May 16, the House Ways and Means Committee advanced seven bipartisan bills to address the opioid crisis. The bills make a number of changes to prevent opioid misuse among seniors and to expand access to addiction treatment services. The House Energy and Commerce Committee, meanwhile, has advanced 57 bills to the House floor. Senate committees are also moving ahead on opioids, though at a slower pace. Following up on the Senate Health, Education, Labor and Pensions (HELP) Committee’s passage of the Opioid Crisis Response Act (S. 2680), the Judiciary Committee on May 24 advanced legislation to reauthorize the Office of National Drug Control Policy (ONDCP), along with other measures to crack down on illicit drug trafficking. Members of the Senate Finance Committee have introduced nearly two dozen opioid-related bills in recent weeks, and the Committee announced plans to mark-up legislation on June 10. President Trump Signs MISSION Act into Law On May 23, Congress advanced long-awaited legislation to reform the Veterans Choice Program and sent the bill to the President. The $55 billion VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION) Act passed the Senate on a 92-5 vote and cleared the House by a vote of 347-70. Among other provisions, the bill consolidates the VA’s community care programs, creates a nonpartisan process for reviewing VA assets to ensure access to care, and provides funding for the Choice Program. President

AMRPA Magazine / July 2018

Trump signed the bill into law on June 6, the 74th anniversary of D-Day. CMS Requests Comments on Reboot of Home Health Pre-Claim Review Demonstration On May 30, the Centers for Medicare and Medicaid Services (CMS) released a request for public comments on a new pre-claim review demonstration for home health services to support the goal of reducing improper payments and lowering Medicare appeal rates. Under the proposal, home health agencies could participate in either 100 percent pre-claim review or 100 percent post-payment review. CMS proposes to impose a 25 percent payment reduction on home health agencies that choose not to participate in the “voluntary” claims review demonstration. CMS initially is seeking to launch the demonstration in Illinois, Ohio, North Carolina, Florida and Texas, with the option to expand to other states in the Palmetto/JM jurisdiction. A similar program was implemented in Illinois in 2016 but proved to do little to improve the identification of fraudulent claims and ultimately was halted due to administrative complexities. The newly proposed demonstration is more expansive, less flexible. Based on Illinois’ previous experience there are serious concerns by home health providers. Comments are due July 30, 2018. Administration Puts Forward Drug Pricing Initiative On May 11, President Trump introduced his administration’s plan to address rising prescription drug prices. The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs identifies key challenges facing the drug market, including high list prices, limited negotiation tools, rising out-of-pocket costs, and foreign governments “free riding” off of American innovation. In addition to outlining previously announced proposals, including those in the President’s Fiscal Year FY19 Budget, the Blueprint proposes a number of “immediate actions” aimed at lowering prices. These include: Changes to strengthen the negotiating power of Medicare Part D plans; Requiring HHS to report on moving certain physicianadministered drugs into Part D; Blocking pharmacy “gag clauses” that prevent pharmacists from telling patients when they could save money by not using insurance; Developing proposals related to the ACA’s maximum rebate provision for Medicaid; Directing the FDA to evaluate the mandatory inclusion of list prices in direct-to-consumer drug advertising; Requiring the FDA to issue guidance to address the ways manufacturers may seek to block or delay generic competition; and

Developing solutions to ensure that U.S. trading partners “contribute their fair share to innovation.” While many of the immediate actions proposed in the Blueprint may be advanced through the regulatory process, others will require enactment of legislation for implementation. The Blueprint also includes a Request for Information (RFI) listing dozens of other issues on which HHS is soliciting stakeholder feedback. The RFI addresses areas such as 340B reforms, value-based arrangements, indication-based payments, access to reference product samples, and site neutrality for physician-administered drugs. HHS will be accepting comments on the RFI through July 16, 2018.

We are looking ahead to several busy months and need your active engagement specifically regarding AMRPA’s concerns regarding CMS’ FY 2019 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) proposed rule. Based on arguably inadequate data, CMS proposes to eliminate the Functional Independence Measure (FIM) instrument in the name of regulatory burden reduction and move to a new IRF case-mix classification system and thus, ultimately impact Medicare payments. We need you to ask your Members of Congress to register opposition to CMS’ current proposal and delay moving forward until any new proposed approach is shown to be a valid and reliable measure of patients’ functional status and accurate predictor of appropriate payment.

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AMRPA Magazine / July 2018

Large Coalition of Rehabilitation Stakeholders Sends Strong Signal to CMS that Bundling Must Measure Patient Function/ Satisfaction

Peter W. Thomas, AMRPA Counsel, and Principal, Powers Law Firm

A large group of disability, consumer, rehabilitation and professional organizations recently sent a strong signal to the Centers for Medicare and Medicaid Services (CMS) that bundled payment initiatives must measure functional outcomes, patient experience with care and patient satisfaction. Forty-three national organizations led by the Coalition to Preserve Rehabilitation (CPR), the Consortium for Citizens with Disabilities (CCD) Health Task Force and the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition wrote to Department of Health and Human Services (HHS) Secretary Alex Azar, CMS Administrator Seema Verma, and the Director of the Center for Medicare and Medicaid Innovation (CMMI), Adam Boehler, commenting on the new voluntary bundled payment model, Bundled Payments for Care Improvementâ&#x20AC;&#x201D;Advanced (BPCI-Advanced) initiative. This letter followed a comprehensive letter to CMMI from AMRPA (reprinted in this issue of AMRPA Magazine) that raised several concerns with the BPCIAdvanced Initiative. The AMRPA letter culminated in a meeting between AMRPA leadership and officials at the Patient Care Models Group at CMMI just days after the coalition letter was delivered, which demonstrated strong support for AMRPAâ&#x20AC;&#x2122;s perspective from a broad coalition of rehabilitation and disability stakeholders. While the coalition letter acknowledged that bundled payment systems seek to reduce expenditures and improve quality of care for Medicare beneficiaries in the fee-for-service program, it argued that without requirements to measure functional outcomes, patient/beneficiary experience and beneficiary satisfaction, there are serious concerns that bundled payment systems may stint on patient care, particularly rehabilitation services and devices. The coalition asked CMMI to consider its comments as CMS staff assess the bundling proposals submitted in the first round of BPCI-Advanced, which is scheduled to be implemented on October 1, 2018, as well as in the second application period starting January 1, 2019. It is important to note that while this comment letter relates specifically to the BPCI-Advanced announcement,

AMRPA Magazine / July 2018

the concepts in this letter equally apply to any Alternative Payment Model (APM) that significantly impacts rehabilitation post-injury or illness, including Accountable Care Organizations (ACOs), shared savings models, and even Medicare Advantage plans. The coalition letter thanked CMS for issuing final regulations in fall 2017 that withdrew the mandatory Cardiac Rehabilitation Incentive Payment Model and limited the scope of the Comprehensive Care for Joint Replacement (CJR) mandatory bundling model. The letter stated that mandatory bundling models, among other things, compromise beneficiary choice of provider, a powerful quality assurance mechanism. Beneficiaries who choose to remain in the Medicare fee-for-service program do so, in part, to maximize patient choice of provider despite ample opportunities to join the Medicare Advantage program where they may obtain additional benefits and cost-sharing but must agree to be served by a more limited provider network. To CMMI’s credit, BPCI-Advanced is a voluntary payment model. It allows providers to choose whether to participate, albeit not post-acute care providers, which is a problem. BPCI-Advanced bundles a specific episode of care (e.g., 90 days) into one lump-sum payment that CMS provides to an Acute Care Hospital (ACH) or a Physician Group Practice (PGP) and allows the bundle-holder flexibility to treat the patient as they deem appropriate. The bundle holder must record data on certain quality metrics and is paid financial incentives if a defined spending target is met while maintaining or improving performance. BPCI-Advanced applies to 32 clinical episodes including stroke, spinal fusions and major joint replacements, to name a few. Depending on the severity of the condition, many of these episodes require significant inpatient and/or outpatient rehabilitation services and devices, including intensive, coordinated and interdisciplinary medical rehabilitation services, to regain or improve functionality after illness or injury. CMMI chose seven quality measures for the BPCI-Advanced model. None of these required quality measures include an assessment of the patient’s functional status either before or after post-acute care (PAC). In short, while CMMI encourages bundled payment applicants to monitor functional outcomes, it does not require participants to measure functional status. The coalition letter stated that “it is alarming that CMMI has chosen to move forward with a new round of bundling proposals that do not mandate reporting and payment consequences for failure to achieve quality outcomes related to patient functional status or patient experience/ satisfaction.” The coalition’s main concern involved the potential of bundled payment systems stinting on patient care in order to achieve cost savings. It is relatively easy to reduce Medicare spending per beneficiary (MSPB) under bundled payment systems, the letter argued, by denying patient access to

// The coalition organizations stressed that functional measures are necessary to assure bundling as a payment model does not jeopardize access to medically necessary rehabilitation services and devices. timely and intensive rehabilitation services and diverting beneficiaries with serious conditions to less intense levels of post-acute care. It is also relatively easy to reduce post-acute care costs by limiting or restricting the amount, duration, and scope of rehabilitation services and devices. The coalition organizations stressed that functional measures are necessary to assure bundling as a payment model does not jeopardize access to medically necessary rehabilitation services and devices. Absent the inclusion of functional measures in this and other demonstrations or delivery models, the coalition organizations stated that they “could find it difficult, if not impossible, to embrace payment models that utilize bundling altogether. The lack of requirements to measure functional outcomes is a major shortcoming of the BPCI-Advanced model and we, therefore, have serious concerns with it as written.” The coalition letter strongly urged CMMI to score most favorably applications that incorporate robust functional outcome measures, and work with applicants to ensure that strong functional measures are added to CMMIapproved BPCI-Advanced bundling programs. The letter also encouraged CMMI to consider measures that assess functional outcomes at time intervals that are longer than the 90-day bundling period (e.g., at six months or one year post-discharge). The letter asserted that functional outcome measures must be directly linked to financial incentives if they are to be effective in preventing stinting of patient care, particularly rehabilitation services and devices. The coalition urged CMMI to score BPCI-Advanced applications that incorporate robust functional outcome and patient satisfaction measures most favorably, and work with all applicants to ensure that strong functional outcome and patient satisfaction measures are added to CMMI-approved BPCI-Advanced programs. The letter asserted that these measures must be directly linked to financial incentives if they are to be effective in preventing stinting of patient care, particularly rehabilitation services and devices.

AMRPA Magazine / July 2018

The coalition stated that “functional measures should focus on factors that include improvements in ADL function but extend well beyond these rudimentary measures. CMMI should also include measures related to discharge rates to the community, improvement in quality of life, pain management, reintegration to community living, level of independence, degree of social interaction, as well as patient experience and patient satisfaction with the care provided.” Finally, the coalition groups stated their regret that CMMI has limited BPCI-Advanced to only one model that provides all of the financial incentives to the Acute Care Hospital or Physician Group Practice. Under Model 3 of the previous version of the BPCI program, post-acute care providers were able to hold the bundle with an assumption that these providers were not only more invested in PAC services, but also knew the potential for improvements in patient care when the beneficiary is timely and appropriately referred to the proper setting and level of intensity of post-acute care. Under BPCI-Advanced, PAC providers will no longer be able to hold the bundled payment, which puts an end to pilot programs and demonstrations that may have been instructive in designing bundled payment programs that do not stint on post-acute care. The coalition stated its concern that acute care hospital and physician group practice bundleholders may inappropriately drive patients to “lower cost,” lower intensity PAC providers and generally limit access to rehabilitation services and devices in order to retain a greater share of the financial incentive. Without robust functional outcome and patient satisfaction measures, the coalition organizations stated that they “fear this result may be inevitable.” Signatories to the Letter Included the Following National Organizations: Academy of Spinal Cord Injury Professionals (ASCIP) ACCSES American Academy of Physical Medicine and Rehabilitation (AAPMandR) American Academy of Neurology (AAN) American Association of People with Disabilities American Association on Health and Disability American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) American Cochlear Implant Alliance American Congress of Rehabilitation Medicine (ACRM) American Dance Therapy Association American Foundation for the Blind (AFB) American Music Therapy Association American Physical Therapy Association (APTA) American Spinal Injury Association (ASIA) American Therapeutic Recreation Association

10 AMRPA Magazine / July 2018

Amputee Coalition The Arc of the United States Association for Education and Rehabilitation of the Blind and Visually Impaired (AER) Association of Academic Physiatrists Association of Assistive Technology Act Programs Association of Rehabilitation Nurses Association of University Centers on Disabilities (AUCD) Autistic Self Advocacy Network Brain Injury Association of America Caregiver Action Network Center for Medicare Advocacy Christopher and Dana Reeve Foundation Clinician Task Force Disability Rights Education and Defense Fund (DREDF) Falling Forward Foundation Lakeshore Foundation The Myositis Association National Association for the Advancement of Orthotics and Prosthetics National Association of Councils on Developmental Disabilities National Association of State Head Injury Administrators National Disability Rights Network National Rehabilitation Association Paralyzed Veterans of America Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) Spine Intervention Society The Simon Foundation for Continence Unite 2 Fight Paralysis United Spinal Association These 43 organizations were led by the Coalition to Preserve Rehabilitation (CPR), the Consortium for Citizens with Disabilities (CCD) Health Task Force and the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition. CPR is a coalition of national consumer, clinician, and membership organizations that advocate for policies to ensure access to rehabilitative care in a variety of inpatient and outpatient settings so that individuals with injuries, illnesses, disabilities, and chronic conditions may regain and/ or maintain their maximum level of health and independent function. CCD is a national coalition of over 100 organizations that advocate on behalf of people with mental, physical, developmental, and intellectual disabilities in a wide variety of subject matter areas, including health care and long term services and supports. ITEM Coalition is a 75-member coalition of national consumer and provider organizations that promotes access to and coverage of assistive devices and technologies for people with disabilities and chronic conditions of all ages.

Understanding the 60% Rule and Tracking Your Compliance

The next topic for review in my self-proclaimed “Year of the PPS Coordinator” is understanding the 60% Rule. This article will serve as a refresher of the 60% Rule, how we track compliance with the rule in eRehabData®, and recommendations for ensuring compliance through your management strategy.

Lisa Werner, MBA, MS, SLP

In order to be paid under the IRF-PPS, at least 60 percent of an inpatient hospital or unit’s patients must require treatment for one of 13 conditions. The Medicare Claims Processing Manual describes the methods used to determine compliance. The first method described for verifying compliance is the “presumptive” methodology. This method uses IRF-PAI data to determine whether a patient meets the IRF-PPS eligibility requirements. Since providers are currently required to submit IRF-PAI’s for Medicare Part A and Medicare MCO/Advantage patients, Medicare can only complete the presumptive review for that population. Additionally, this method of calculation can only be used when the IRF’s Medicare patient population is representative of their total population. It is deemed representative if 50 percent or more of the IRF’s population is comprised of Medicare Part A fee-for-service patients and Medicare MCO patients as long as the provider has at least 100 discharges in a year. According to the documentation, the presumptive review is completed by examining the IRF-PAI for the presence of an impairment group code or ICD-10 code entered as either the etiologic diagnosis or as a comorbid condition listed in §412.23(b)(2)(ii) of the Medicare Benefit Policy Manual (MBPM). If a matching code is found, it is counted as compliant (some exclusions apply). If 60 percent or more of the IRF-PAI’s reviewed have a compliant code, the presumptive compliance threshold is met. If the rehabilitation hospital/unit’s population does not meet the 50 percent threshold of Medicare Part A fee-for-service and Medicare MCO patients, an alternate method of review is employed. This is called “medical review.” In this

AMRPA Magazine / July 2018 11

method, the Medicare contractor reviews a sample of the provider’s medical records in order to determine compliance. If the provider has a total population of fewer than 100 discharges, the contractor will review all of the provider’s medical records. Medical review is also used when a provider fails a presumptive review. However, a contractor can use medical review any time to substantiate the results of the presumptive review. During a medical record review, the auditor should be looking for evidence of the conditions of compliance spelled out in the Medicare Benefit Provider Manual. Patients who presumptively comply with the rule can be discarded under medical record review if the documentation does not prove that the patient required inpatient rehabilitation services for a qualifying condition. For example, a patient admitted with a cardiac impairment group might also have a history of an old stroke with ongoing hemiplegia. The old stroke with hemiplegia will trigger presumptive compliance, but it might be an underlying comorbidity that was not the reason for admission. In order for the CMS auditor to count the case as compliant under medical review, the documentation would have to prove that the patient required a rehabilitation stay in the absence of the admitting (cardiac) condition. Anecdotally, in the consulting work that I do, I find that the physician and team documentation rarely backs up a comorbidity as an alternate primary reason for admission. On your eRehabData® report, there is a bolded category for FY2016+ presumptive compliance and presumptive without comorbidities for cases Transmitted to CMS. This represents the data that Medicare will see within their database, populated by the records you submitted. This should be the first place you focus your attention when gauging your compliance through Medicare’s lens. Step two is to look at your compliance in the bolded category for conditional compliance for all payers. In this category, compliant impairment group codes are counted, but exclusions such as non-traumatic spinal cord injury paired with the etiologic diagnosis of spinal stenosis are not counted as compliant. Conditional compliance for all payers also includes records marked as compliant according to the Medicare Benefits Policy Manual (MBPM) on the eRD tab, as well as records that have clearly compliant impairment group codes (such as 01.1 or 08.62). Make sure that at the end of your compliance year, this percentage is at or above 60 percent. This is one way to track how you would fare under a chart review for compliance. I strongly recommend that you watch that percentage closely. Your compliance strategy may vary depending on your risk tolerance and willingness to fight the case for compliance.

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// The most important thing a provider can do is review their 60% Rule compliance report on a regular basis to ensure that patients are properly classified. In eRehabData® we offer you the ability to mark “yes” or “no” on the eRD tab when a patient has a presumptively compliant code that could make them conditionally compliant. The PPS coordinator is asked to distinguish whether or not the case should be marked compliant for 60% Rule Report calculation purposes only. When you mark a case as conditionally compliant, you are attesting to the fact that you feel there is sufficient documentation to show that the case meets the conditions of compliance set out in the 60% Rule. One example of a presumptively compliant case that should be marked conditionally compliant is when the compliant condition is the reason for admission or etiologic diagnosis. For example, Guillain-Barre carries the IGC 3.4. That IGC was not included in the presumptively compliant list released by Medicare, but the condition was listed as compliant in the final rule. Therefore, I recommend that you mark the eRD tab as “yes” when you have a patient whose IGC is 3.4 and whose etiologic diagnosis is 357.0 (acute infective polyneuritis). In fact, in the majority of cases, when the information spelled out on the eRD tab indicates that a question of compliance is raised due to the patient’s etiologic diagnosis, you can safely mark “yes” on the eRD to show compliance. There is, however, one exception. When the diagnosis is an acetabullar fracture, I do not recommend marking “yes” on the eRD tab because the language in the MBPM states this condition would be compliant under the IGC of “hip fracture,” which is further defined as a fracture of the femur. The acetabullum, not being part of the femur, would not meet this specification. Further, the rule of thumb is that when the condition flagging compliance on the eRD tab is a condition that you listed in the comorbidity item #24 on the IRF-PAI, you would most commonly check “no” to answer the question. It is rare that you will have adequate documentation to reflect that the patient would have needed a stay in an inpatient rehabilitation hospital or unit for that condition in the absence of their admitting condition. That is the threshold for answering “yes” to the question on the eRD tab. My extremely simplified version of how to manage the eRD tab boils down to this: check “yes” when the etiologic diagnosis triggers the tab to turn yellow (except when the diagnosis is an acetabullar fracture); check “no” when a comorbidity triggers the tab to turn yellow.

The most important thing a provider can do is review their 60% Rule compliance report on a regular basis to ensure that patients are properly classified. You should be checking for potential coding errors, such as a patient with a diagnosis of a hip fracture paired with a hip replacement impairment group. Also, peruse the list of patients in the report filtered by “presumptive, not conditional” to ensure that patients are checked as conditionally compliant as you expected. If your IRF-PAI coders are not completing the conditional compliance information on individual assessments, you may notice a larger number of patients than expected listed as “presumptive, not conditional,” in which case you should review the “conditional, not conservative conditional” list as

well. Make sure that you are keeping track of your admissions and staying within your planned compliance strategy. If you are feeling adventurous, you may also want to spot check the documentation of cases marked as conditionally compliant based on a comorbidity to ensure that the record supports the comorbidity as the primary need for inpatient rehabilitation services. Call +1-202-588-1766 anytime to learn more about our 60% Rule compliance report, outcomes reports or other eRehabData® advantages.

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AMRPA: Working Together to Preserve Preserve Access to Medical Rehabilitation AMRPA: Working Together To Access To Medical Rehabilitation Maggie Ramirez VP of Membership Services · 347-573-3732 · mramirez@amrpa.org Samantha Schwarz,· AMRPA Member Services Coordinator, 202-207-1132, sschwarz@amrpa.org

AMRPA Magazine / July 2018 13

CMS Proposes to Reinstate the Home Health Pre-Claim Review Demonstration

On May 31, the Centers for Medicare and Medicaid Services (CMS) issued a notice in the Federal Register seeking public comment on a demonstration titled, “Pre-Claim Review Demonstration for Home Health Services.” Pursuant to this notice, CMS seeks to implement a Medicare demonstration project that it believes will help assist in identifying Medicare fraud occurring among home health agencies (HHAs). Comments are due to CMS by July 30, 2018.

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

The demonstration would begin October 1, 2018, and last five years. CMS initially proposed a similar pre-claim review demonstration program in 2016 and then withdrew it on April 1, 2017, due to stakeholder response. AMRPA filed a comment letter expressing serious concerns about the 2016 proposal. AMRPA urged that home health services following an acute care or post-acute hospital stay be exempted from the demonstration. According to CMS, this new demonstration, now titled, “Review Choice Demonstration for Home Health Services,” would use either pre-claim or postpayment review to help make sure that payments for home health services are appropriate. CMS proposes to implement the demonstration in Illinois, Ohio, North Carolina, Florida and Texas with the option to expand to other states in the Palmetto/JM jurisdiction. If there is increased evidence of fraud, waste or abuse in these states during the demonstration period, CMS may expand to other states in the Palmetto/JM Home Health and Hospice Medicare Administrative Contractor (MAC) jurisdiction. According to the agency, these states include known areas of fraudulent behavior and had either a high home health improper payment rate or a high denial rate during the Home Health Probe and Educate reviews. Under this demonstration, CMS offers three choices for providers to demonstrate their compliance with Medicare’s home health policies. Providers in the demonstration states may participate in either 100 percent pre-claim review, 100 percent post-payment review, or option three: not participate (continuing to

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submit claims for payment without undergoing such review) but receive a 25 percent payment reduction on associated claims. CMS further provides a strong incentive to participate in that nonparticipating providers may be subject to review by the Recovery Audit Contractors in addition to the 25 percent payment reduction. Participating providers will continue to be subject to a review method until the HHA reaches the target affirmation or claim approval rate. Once a HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of their claims to ensure continued compliance. Under the pre-claim review option, HHAs will send the preclaim review request along with all required documentation to the Medicare contractor for review prior to submitting the final claim for payment. If a claim is submitted without a pre-claim review decision on file, the Medicare contractor will request the information from the HHA to determine if payment is appropriate. Per CMS, pre-claim review is a process through which a request for provisional affirmation of coverage is submitted for review before a final claim is submitted for payment, and can occur after services have been provided. From CMS’ perspective, pre-claim review helps ensure that applicable coverage, payment and coding rules are met before the final claim is submitted. CMS states that pre-claim review does not create new documentation requirements. HHAs will submit the same information they are currently required to maintain for payment. CMS views pre-claim review as being different than prior authorization due to the timing of the review and when services may begin. For prior authorization, a request must be submitted prior to services beginning and providers should wait until they have a decision before they begin providing services. With pre-claim review, services can begin, and the request is submitted after all of the initial assessments and intake procedures are completed and services have begun. Pre-claim review occurs after services start but prior to the final claim being submitted. For the post-payment review option, the Medicare contractor will also request the information from the HHA that submitted the claim for payment to determine if payment was appropriate. CMS believes that the revised demonstration should have minimal effect on beneficiaries and does not alter the Medicare home health benefit. As noted under the pre-claim option, the pre-claim review request can occur after home health services have started. The pre-claim review request must be submitted and reviewed before the final claim is submitted for payment. The post-payment review option and minimal post-payment review with a 25 percent payment reduction option would occur after the beneficiary has received the home health services.

// Providers in the demonstration states may participate in either 100 percent pre-claim review, 100 percent post-payment review, or option three: not participate (continuing to submit claims for payment without undergoing such review) but receive a 25 percent payment reduction on associated claims. GAO Recommendations for Medicare’s Prior Authorization Programs Notably in May, the Government Accountability Office (GAO) released a report on CMS’ prior authorization programs titled, “CMS Should Take Actions to Continue Prior Authorization Efforts to Reduce Spending.” GAO was asked to examine CMS’ prior authorization programs. GAO evaluated 1) the changes in expenditures and the potential savings for items and services subject to prior authorization demonstrations; 2) reported benefits and challenges of prior authorization; and 3) CMS’s monitoring of the programs and plans for future prior authorization. To do this, GAO inspected prior authorization program data, CMS documentation, and federal internal control standards. GAO also interviewed CMS and MAC officials, as well as selected provider, supplier, and beneficiary groups. GAO noted that prior authorization is a payment approach used by private insurers that generally requires health care providers and suppliers to first demonstrate compliance with coverage and payment rules before certain items or services are provided to patients, rather than after the items or services have been provided. GAO was aware of CMS’ prior authorization demonstrations and one permanent program. For instance, GAO examined the durable medical equipment (DME) competitive bidding program initiated in January 2011, which has, according to CMS, resulted in lower expenditures. However, the program has been controversial with DME suppliers and providers.

AMRPA Magazine / July 2018 15

According to GAO’s analyses, expenditures decreased for items and services subject to a demonstration. GAO’s analyses of actual expenditures and estimated expenditures in the absence of the demonstrations found that estimated savings from all demonstrations through March 2017 could be as high as about $1.1 to $1.9 billion. While CMS officials said that prior authorization likely played a large role in reducing expenditures, GAO felt it was difficult to separate the effects of prior authorization from other program integrity efforts. CMS monitors prior authorization through various MAC reports. CMS also reviews MACs’ accuracy and timeliness in processing prior authorization requests and has contracted for independent evaluations of the demonstrations. Currently, prior authorization demonstrations are scheduled to end in 2018. GAO further stated that despite its interest in using prior authorization for additional items, CMS has not made plans to continue its efforts.

The report includes several recommendations to CMS. One of the recommendations was that the administrator of CMS should take steps, based on results from evaluations, to continue prior authorization. These steps could include: 1) resuming the paused home health services demonstration; 2) extending current demonstrations; or 3) identifying new opportunities for expanding prior authorization to additional items and services with high unnecessary utilization and high improper payment rates. In response, CMS neither agreed nor disagreed with the GAO’s recommendations but said it would take them into consideration in evaluating the agency’s prior authorization programs.

Let’s Stay in Touch

AMRPA has new phone and fax numbers. Please see the changes below to update your records. AMRPA Government Relations & Policy Team AMRPA Main Phone: 202-591-2469 Fax: 202-591-2445

Mimi Zhang, AMRPA Senior Policy and Research Analyst Direct Phone Line: 202-860-1003

Carolyn Zollar, JD, MA, AMRPA EVP for Government Relations and Policy Development Direct Phone Line: 202-860-1002

Lovelyn Robinson, AMRPA Editorial and Research Assistant Direct Phone Line: 202-860-1005

Jonathan Gold, JD, AMRPA Regulatory and Government Relations Counsel Direct Phone Line: 202-860-1004

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Catherine Beal, AMRPA Staff Associate Direct Phone Line: 202-860-1006

Kaiser Family Foundation: Affordable Care Act’s Insurance Marketplaces Continue to Stabilize

An updated report from the Henry J. Kaiser Family Foundation (KFF) finds the individual insurance marketplaces under the Affordable Care Act (ACA) continue to stabilize and become profitable for insurers, with no evidence of a potential market collapse. The findings are informative for policymakers and health care providers in light of concerns surrounding the stability and sustainability of the ACA’s individual insurance marketplace.

Mimi Zhang, AMRPA Senior Policy and Research Analyst

Highlights: »»

Plans’ financial performance show that the ACA’s exchanges marketplace continued to stabilize through 2017, following a multiyear trend.

»»

Nonetheless, recent policy changes have the potential to destabilize the individual market.

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The latest data through 2017 show that insurers in the individual market continue to regain profitability and the study authors can detect no signals of a market collapse. However, they also note that it remains to be seen how recent policy changes – such as the repeal of the individual mandate and proposed rules to expand short-term coverage plans (which are not ACA-compliant) – will impact the future stability of the marketplace. KFF used data reported by insurance companies to the National Association of Insurance Commissioners to evaluate trends in average premiums, claims, medial loss ratios (MLR), gross margins and enrollee utilization from 2011 through 2017. The data include plans purchased through the ACA’s exchange marketplaces and ACA-compliant plans purchased directly from insurers outside the marketplace. It also includes individual plans purchased before the ACA went into effect. Medical Loss Ratios The researchers had previously found that insurer financial performance, as measured by MLRs, worsened in the earliest years of the ACA but has improved in more recent years. MLRs are the proportion of health premiums being paid out as enrollee claims. Higher MLRs mean more of insurers’ income is being paid out as claims and it is unlikely for insurers to be profitable when MLRs exceed 85-90 percent due to the relatively high cost of administering individual market plans, according to the KFF.

Figure 1: Average individual market medical loss rations, 2011-2017

// Not only have premiums continued to increase but the growth in expenses (as claims paid out) has also decreased in recent years. MLRs first began declining in 2016, and performance significantly improved last year primarily due to higher premiums. The average MLR was 82 percent in 2017, continuing the downward trend (see Figure 1). The researchers attribute this stabilization to insurers being more experienced with the individual market and having sufficient actuarial data to better predict costs.

Figure 2: Average individual market gross margins per member per month, 2011-2017

Margins Researchers also looked at the average gross margins per member per month (PMPM). This is the average amount that premium incomes exceed the cost of claims paid out by insurers, in a given month. In 2017, average margins grew to $78.52 per enrollee from a low of -$9.21 in 2015 (see Figure 2). Although gross margins are an indicator of performance, margins do not account for administrative costs and therefore positive margins do not necessarily mean profitability. Nonetheless, growing gross margins PMPM are another sign that financial performance for individual marketplace insurers are on course to return to pre-ACA levels of profitability. The Department of Health and Human Services under the Trump administration stopped payments for cost-sharing subsidies in October 2017. While losing these payments did diminish profits in the final months of 2017, insurers still experienced better financial results last year than they did in earlier years of the ACA.

Figure 3: Average individual market monthly premiums and clams per person, 2011-2017

Not only have premiums continued to increase but the growth in expenses (as claims paid out) has also decreased in recent years. Between 2016 and 2017, enrollee premiums grew 22 percent on average while per-enrollee claims grew 5 percent (see Figure 3). Enrollees in 2017 were not noticeably sicker than previous years, as evidenced by a stable enrollee hospitalization rate. The average number of days spent in a hospital has stayed steady since 2015 at approximately 26 days per 1,000 enrollees. This suggests that the individual market risk pool is relatively stable. Enrollees in ACA plans are sicker on average than the pre-ACA market, which is not unexpected since people with pre-existing conditions were not guaranteed coverage prior to the ACA. The study, Individual Insurance Market Performance in 2017, can be found on the KFF website here: https://www.kff. org/health-reform/issue-brief/individual-insurance-marketperformance-in-2017/.

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Medicare Trustees: Part A Trust Fund to be Bankrupt by 2026

The Board of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds issued their annual report on June 5, detailing the status and issuing projections on the trusts that fund Medicare. Most notably, the board projects that the Medicare Part A Trust Fund will be depleted by 2026, three years earlier than their last projection.

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

Highlights: »»

Latest Medicare Trustees Report projects increased Medicare spending, enrollment outpacing income.

»»

Part B and D funds will remain stable due to increased beneficiary premiums.

The report attributes the acceleration of the depletion of the Part A Trust to several income and spending changes since last year’s report. The board states that income for the Part A Trust will be lower than previously expected due to lower payroll taxes and lower levels of taxation on Social Security benefits as a result of recent legislation. Spending is also projected to be higher due to higher-than-expected expenditures in 2017, legislation that increased hospital spending, and higher Medicare Advantage payments, according to the report. The trustees state that their projections also show that Medicare tax income and other dedicated revenues for funding the Part A Trust will continue to fall short in future years. The trustees recommend that Congress and the executive branch work closely together in an urgent manner to address the depletion of the Part A fund. The sooner reforms are in place, according to the board, the more gradually they can be implemented and that allows for all stakeholders to adjust to the changes.

// The trustees state that their projections also show that Medicare tax income and other dedicated revenues for funding the Part A Trust will continue to fall short in future years. AMRPA Magazine / July 2018 21

Figure 1: HI Trust Fund balance at the beginning of year as a percentage of annual expenditures

For the Supplemental Medical Insurance Trust Fund (SMI), which funds Part B and Part D of Medicare, the trustees reported that they project the fund will be adequately financed over the next 10 years. The report says that since premiums are reset each year to cover expected costs, general revenue remains adequate to continue to fund the trust. For Part B, the trustees say expenditures grew at an average annual rate of 5.5 percent over the past five years, exceeding Gross Domestic Product (GDP) growth by 1.8 percentage points annually, on average. Further, the Board projects Part B cost increases to average about 8.2 percent for the five-year period between 2018 to 2022, which outpaces the expected GDP growth rate of 4.7 percent for the same time period. Beneficiary premiums will need to be raised if no other dedicated funding sources are provided to account for these increases.

Figure 2: SMI expenditures and premiums as a percentage of the Gross Domestic Product

For the Part D account, the trustees project that expenditures will grow at an average annual rate of 6.9 percent over the 10-year period 2018 to 2027, due to increases in enrollment and growth in per capita drug costs. As with Part B, increases in premiums for Part D beneficiaries will need to be made to match these increases. In all, the board says total Medicare expenditures were $710 billion in 2017. The board also projects that aggregate Medicare expenditures will increase at a faster pace than either workersâ&#x20AC;&#x2122; earnings or the economy overall, and that Medicare spending will increase from 3.7 percent of GDP in 2017 to 6.2 percent by 2092. Read the full report on the CMS website.

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AMRPA Responds To Call for Public Comment on the Transfer of Health Information Editor’s Note: On May 3, 2018, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Centers for Medicare and Medicaid Services (CMS) and RTI International in response to the Call for Public Comment on the Transfer of Health Information – Medication Profile quality measures under development for post-acute care (PAC) providers. The complete letter is provided below.

May 3, 2018 RTI International 3040 E Cornwallis Road Durham, NC 27709 Delivered electronically to TOHPublicComments@rti.org. Re: Request for Comments on “Transfer of Health Information and Care Preferences When an Individual Transition - Medication Profile Transferred to Provider / Medication Profile Transferred to Patients” To RTI International and the Centers for Medicare and Medicaid Services: This comment letter is submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) in response to the Call for Public Comment on the Transfer of Health Information – Medication Profile quality measures under development for post-acute care (PAC) providers pursuant to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The measures are: 1. Medication Profile Transferred to Subsequent Provider (Q1) 2. Medication Profile Transferred to Patient (Q2) AMRPA is the national trade association representing more than 600 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 care provided in non-hospital post-acute 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. AMRPA has reviewed the report prepared by RTI International, Draft Specifications for the Medication Profile Transferred Measures for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies. The comments contained in this letter reflect feedback received from AMRPA’s Quality Committee with input from pharmacists, administrators, physicians and other clinicians at rehabilitation hospitals and units. I. General comments On behalf of our members, AMRPA would like to first and foremost thank CMS and its measure developers for scaling back the scope of data collection and reporting burden associated with the Transfer of Health Information quality measures. When the first iteration of the Transfer of Health Information measures was issued in November 2016, it encompassed a far wider range of patient data elements beyond medication information, including but not limited to functional and cognitive

AMRPA Magazine / July 2018 23

status, medical conditions and comorbidities, and discharge instructions. In addition, one of those measures also proposed to hold PAC providers accountable for the information transfer behavior of upstream referral sources, which providers have little ability to influence. Hence, we appreciate the agency’s consideration of the stakeholder feedback it received in response to the first iteration. Although the revised measures address several of our prior concerns, we respectfully submit that a number of additional revisions remain necessary. AMRPA supports the intent of the newly specified measures, Medication Profile Transferred to Subsequent Provider and Medication Profile Transferred to Patient. Our members agree that the accurate and successful transfer of essential medication information at PAC discharge/transfer is critical to ensuring that patient safety and quality of care are not compromised once a patient leaves a particular setting. While the draft report details the types of medication information included in these measures (in the form of 25 Medication Profile data elements), it fails to delineate how exactly the data elements will be implemented across PAC settings. Specifically, the draft specification report fails to adequately address the following operational questions: How would CMS collect the Medication Profile data elements? Would they be categorized as standardized patient assessment data elements (SPADEs) and thus constitute mandatory reporting on PAC patient assessment instruments pursuant to PAC Quality Reporting Programs’ data completion thresholds? While the report references that the IMPACT Act mandates the collection of SPADEs, it does not specify if the Medication Profile data items would indeed be categorized as SPADEs. If the Medication Profile elements will be SPADEs, would the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI) need to be revised to include medication data items? If not, would CMS validate the completion of the Medication Profile data items against what providers selfreport on the quality measures? How would the agency ensure validity for these process-based measures? How would the measures integrate with medication reconciliation or discharge planning processes already in place at IRH/Us and other hospitals? What are the qualifications of clinical personnel allowed to complete the Medication Profile? Medication reconciliation is a complex process at hospitals, and IRH/Us already dedicate extensive administrative resources and staff time from pharmacists, physicians, nurses, and other clinicians to ensure that it is being done appropriately. Accordingly, we view the current comment opportunity as

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the start of a dialogue with CMS regarding the optimal way to achieve the agency’s objective of promoting effective medication information transfer at PAC discharge/transfer. AMRPA looks forward to working further with CMS and responding to its future proposals specific to the collection of the Medication Profile data items. As CMS continues to develop a reporting mechanism, we urge the agency to do so in a practical and minimally burdensome manner that adds value beyond IRH/Us’ current medication reconciliation and/ or discharge planning practices. This would be consistent with CMS’ Patients over Paperwork and Meaningful Measures initiatives which aim to reduce providers’ administrative burden, and specifically with regard to burden from quality measures. Our recommendation for CMS to focus on an “essential medication information” list, detailed further below, aims to achieve these goals. II. Medication Profile Definition CMS proposes that the Medication Profile transmitted at discharge/transfer “be seen as a comprehensive summary of information for the current prescribed and over the counter (OTC) medications, nutritional supplements, vitamins, and homeopathic and herbal products administered by any route to the patient,” including total parenteral nutrition (TPN) and oxygen. To that end, CMS proposes the medication profile to include “at least all” of the 25 data elements, as summarized in the table below. According to our members, IRH/Us already communicate these data through medication reconciliation, discharge planning processes, and other clinical protocols. This information is located in sources such as the discharge summary, a Medication Administration Record (MAR), home medication lists or the physician orders. We think a Medication Profile, for the purposes of a cross-setting PAC standardized IMPACT Act measure, should focus on the core and essential medication information, and not duplicate the comprehensive summary of medication information IRH/Us already communicate to subsequent providers and patients. The profile should be limited to those pieces of medication information for which there is uniform consensus on their clinical importance. We posit that a cross-setting Medication Profile concentrating on the core or essential medication information could be defined as: “A Medication Profile is a patient-specific list of prescribed medications the transferring/discharging care team intends the patient to continue taking upon transfer/discharge, including sufficient detail (dose/ frequency/end date, if predetermined) to allow the profile to guide subsequent patient/provider behavior.” The table below contains our recommendations regarding the 25 Medication Profile data elements specified in the draft report, and reflects those elements of medication information that our clinician members find as essential for transfer at patient discharge/transfer.

Proposed Medication Profile Item

AMRPA Recommendations and Rationale (Recommended changes/revisions to items are in bold, and recommended items for removal are in italics.)

Patient Information on the Medication Profile 1. Patient name

We support including this item.

2. Patient date of birth

We support including this item.

3. Primary physician name and contact information

We recommend CMS revise this item to refer specifically to the PAC physician overseeing the patient transition, since this physician will be whom the downstream physician would need to contact regarding information in the Medication Profile. As the item is currently written, it is unclear if “primary physician” refers to the patient’s primary care physician, the primary physician at the PAC setting, or the attending physician from an upstream acute care hospital.

4. Height and date taken *If applicable 5. Weight and date taken *If applicable 6. Patient active diagnoses and any other diagnoses that have medication implications 7. Known medication and other allergies 8. Known drug sensitivities and reactions

Because these data are already included elsewhere in the medical record or discharge summary, we would not support their additional inclusion in a Medication Profile. We recommend these items be collapsed into one item and limited to “Known medication allergies and intolerances.” Some medications have known side effects such as nausea or discomfort, but that should not be misinterpreted by the next site of care as a reason to not administer the medication. We are concerned that requiring providers to document all known sensitivities and reactions on the Medication Profile could open a Pandora’s box of unintended misinterpretations.

9. Patient preferences (e.g., preferred packaging such as no childproof lids, form of medication such as time-released medication, how medication information is provided to patient) *If applicable

We do not support including these items. A subsequent care setting will prepare the patient’s medications and hence these types of “patient preferences” would neither be highly useful nor meaningful. If a patient is at home and receiving prescriptions from a pharmacy, patient preferences regarding packaging are kept on file at the outpatient pharmacy. Additionally, time-released medication is a clinical decision made by the provider, not a patient preference. AMRPA recognizes that the IMPACT Act requires CMS to collect data on patient care preferences. We encourage the agency to define and focus on other care preferences data items that would be much more meaningful to patients and providers.

10. Patient adherence strategies (e.g., alarms, drug diaries) *If applicable

We do not support including this item in the Medication Profile. These are medication management strategies better reflected in the patient’s comprehensive care plan. They are not suited for the Medication Profile which should be focused on transmitting essential medication information.

11. Patient ability to understand/accept condition(s) and importance of taking medications as prescribed

We do not support including this item. It assesses a patient’s cognitive function and ability to understand the information being presented and therefore is outside the scope of Medication Profile. IRH/Us already have discharge planning processes for a clinician to review the medication list with patients/family/caregivers and take the necessary steps to ensure that they understand it.

Medication Information Items – To Be Completed for Each Medication Proposed Medication Profile Item

AMRPA Recommendations and Rationale

12. Name (generic and proprietary names if applicable) and strength

We support the intent of this item but recommend that it be clarified to require a generic name. Various national standards indicate that medications should not be referenced by brand name only. This item should focus on the essential information needed to communicate a drug name and not burden providers to document all of the drug’s known identifiers. As a suggestion, the item could be revised to “Name (generic only OR if proprietary name, also include generic) and strength.”

13. Dose

We support including this item.

14. Route of medication administration

We support including this item.

15. Frequency

We support including this item.

16. Directions

We think this information is already being captured by Items 13-15, and therefore recommend that Items 16 and 17 be designated as “If applicable.” This approach would allow the discharging/transferring provider to document additional directions they feel are important to communicate to the next site of care (such as take with a meal, take with a full glass of water, etc.), but would not impose unnecessary reporting burden.

17. Special instruction (e.g., crush medications) *If applicable

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18. (For held medications) Reason for holding medication and when medication should resume

We support including this item. It is critical to accurately document those drugs that are part of the patient’s routine medication regimen but were temporarily held/suspended, and need to resume at a later date. These medications and their resumption dates should be highlighted for the next site of care in the Medication Profile.

19. Purpose/Indications/Contraindications

We recommend CMS revise this item to “Purpose (i.e., condition being treated)” and remove “Indications/Contraindications.”

20. Prescriber (for prescribed medications only)

Similar to Item 3, we request CMS revise this item to refer specifically to those medications prescribed by the PAC physician when the patient was under their care.

21. When the last dose of the medication was administered by discharging/transferring provider *If applicable

We do not support including this item in the Medication Profile. While we agree that this is a key piece of information, the specific timeliness of administered drugs is better captured through a MAR than in the Medication Profile. Furthermore, we are concerned that retaining this item could unintentionally structure the Medication Profile to become a prescriptive protocol that must be completed as close to the point of discharge as possible so as to capture the most current data. However, this would defeat the purpose of having the Medication Profile be completed in a comprehensive and deliberate manner, which is an especially relevant consideration for those providers using paper medical records.

22. When the final dose of the medication should be given *If applicable

We recommend this is combined with Item 15 - Frequency and be an optional field, e.g., “Frequency (including planned stop date/when the final dose should be given, if known).”

23. Patient education provided about potential risks/side effects/contradictions and when to notify prescriber (for profile provided to patient/family/caregiver)

We do not support including these items in the Medication Profile. These are medication management strategies better reflected in the patient’s comprehensive care plan.

24. Patient adherence with the medication therapy 25. Relevant lab test results to guide medication management (e.g., serum creatinine) *If applicable

We do not support including this item in the Medication Profile. Providers have different routines regarding lab tests so there would be a high degree of variance in institutional practices that would not lend itself to meaningful reporting on a standardized item. In addition, this item detracts from the value of the physician’s clinical judgement since it is not a standard of practice for physicians to base their orders solely on lab results.

III. Measure Specifications A. Inclusion Criteria: Aligning Beneficiary Populations One of the primary objectives of the IMPACT Act is to collect comparable data across all four PAC settings. This objective implies that the collected data and quality information are aligned across settings for there to be a true comparison. However, CMS’ quality measures continue to fall far short of this goal because they capture vastly different Medicare beneficiary populations and are not fully standardized across settings. Specific to the Transfer of Health Medication Profile measures, the proposed beneficiary inclusion criteria are as follows: IRH/Us: The denominator is the total number of Medicare Part A and Medicare Advantage (Part C) patient stays ending in discharge/transfer. LTCHs: Total number of LTCH patient stays, regardless of payer, ending in a discharge/transfer to another setting. SNF: Total number of SNF Medicare Part A covered resident stays ending in a discharge/transfer to another setting. HHA: Total number of Medicare Part A, Medicare Advantage (Part C) and Medicaid home health quality episodes ending in a discharge/transfer to another setting. Without an alignment of assessed patient populations, any data collected through these measures may have systemic sampling biases that would not allow for an apples-to-apples comparison. AMRPA urges CMS to prioritize cross-setting standardization as it develops and implements IMPACT Act 26 AMRPA Magazine / July 2018

quality measures, and recommends the measures be applied to a uniform Medicare patient population that is inclusive of Medicare Parts A and C beneficiaries. Short of this, CMS should use a uniform patient population that is the lowest common denominator, which would be Part A beneficiaries, for purposes of cross-setting comparisons and for public reporting. This would result in an apples-to-apples comparison across settings, which is the purpose of this data collection. Failing to standardize the patient population across settings will result in selective sampling that skews the collected data, and distorts or otherwise invalidates meaningful comparisons across measures and across PAC settings. B. Aligning Item Responses across PAC Settings For measure Q1A, CMS proposes a response option that is available only to HHAs as follows: Medication Profile Transferred to Subsequent Provider Q1A: At the time of discharge/transfer to another provider, did your facility/agency provide the patient’s/resident’s current medication profile to the subsequent provider? 1. Yes – Current medication profile provided to the subsequent provider 2. No – Current medication profile not provided to the subsequent provider 3. NA (Home Health Transfer only) – The agency was not made aware of this transfer timely. (emphasis added)

We do not think the Not Applicable (NA) option should be limited to HHAs since patients in other PAC settings also experience unexpected discharge/transfers when they return

to the acute care hospital due to an emergent incident. This is recognized as the “interrupted stay” payment adjustment under the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). In these cases, the IRH/U will certainly prioritize the patient’s timely transfer to the necessary care setting, and it would be inappropriate for CMS to hold providers accountable to a reporting process over patient wellbeing. We recommend CMS revise the NA option to make it available as a response for all PAC settings. C. Clarifying Included Patient Subsets Per the specifications, both measures Q1 and Q2 include patients who are discharged/transferred to “home under care of an organized home health service organization or hospice.” Since the two measures are intended to differentiate between patients who transfer to a subsequent provider versus those who return to home/community, this design would seem to double count a subset of patients. We request CMS revisit this measure specification to clarify or wholly remove the apparent overlap. In our view, patients who receive care in home-based hospice should be included in the home/ community measure (Q2), whereas patients who receive care in institutional-based hospice should be included in the subsequent provider measure (Q1). IV. Routes of Information Transfer The proposed routes (electronic medical records (EMRs), health information exchange, paper, verbal) are appropriate and we do not have recommendations regarding these routes. To address CMS’ questions to stakeholders on this topic: We do not think consumers will find high value in knowing the routes by which their medication profile was transmitted, nor is this information likely to inform their choice of PAC providers. There are many other criteria (quality and outcomes of care, location/proximity, etc.) that are far stronger drivers in a patient’s decision regarding their PAC provider. The existing health IT standards do not support interoperable exchange of medication data elements. Even if a discharging provider is able to electronically transmit medication (and other types of) information to a provider downstream, it is often the case that the second provider cannot receive and integrate the data into their EMR.

The IMPACT Act recognizes the extant interoperability challenges and thereby mandates CMS to make interoperable standardized patient assessment and quality measurement data. AMRPA understands that CMS is currently working on making items interoperable via its Data Elements Library (DEL) project, and collaborates with health information technology (HIT) content standards bodies and HIT vendors as part of this project. If it is CMS’ intent to promote the electronic transfer of medication information via a standardized Medication Profile, AMRPA recommends the agency leverage its partnerships with HIT and EMR vendors and determine how any new information transfer “standard” can be optimally implemented across provider settings. EMR vendors already work closely with most health care providers and would be able to offer CMS critical guidance regarding the design and feasibility of any standardized approach to cross-setting electronic data transfer. V. Conclusion AMRPA appreciates the opportunity to provide input on the development of cross-setting standardized PAC quality measures and their proposed specifications. We seek to ensure these elements achieve the objectives of the IMPACT Act while being minimally burdensome for PAC providers. If you have any questions, please contact Carolyn Zollar, J.D., Executive Vice President for Government Relations and Policy Development (czollar@amrpa.org) and Mimi Zhang, AMRPA Senior Policy and Research Analyst (mzhang@amrpa.org) at 202-591-2469. 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 Administrator, Carolinas Rehabilitation – Charlotte Vice President, Continuing Care Division of Carolinas HealthCare System

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AMRPA Submits Comments to CMS’ Innovation Center on the Implementation of BPCI Advanced Editor’s Note: On May 1, 2018, the American Medical Rehabilitation Providers submitted comments to Center for Medicare and Medicaid Innovation’s regarding the Bundled Payment for Care Improvement (BPCI) Advanced model. The complete letter is provided below.

May 1, 2018 The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services 7500 Security Blvd. Baltimore, MD 21244 Amy Bassano Deputy Director Center for Medicare and Medicaid Innovation 7500 Security Blvd. Baltimore, MD 21244 Adam Boehler Deputy Administrator for Innovation and Quality and Director Center for Medicare and Medicaid Innovation 7500 Security Blvd. Baltimore, MD 21244 Re: Bundled Payment for Care Improvement (BPCI) Advanced Dear Administrator Verma, Director Boehler, and Deputy Director Administrator Bassano: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we write in response to the Center for Medicare and Medicaid Innovation’s (Innovation Center) announcement of the Bundled Payment for Care Improvement (BPCI) Advanced model. Like many health care providers, AMRPA members have been anticipating BPCI Advanced since the model was first referenced in the Episode Payment Models (EPM) final rule last year. However, we and our members were disappointed by the scope and nature of BPCI Advanced, most specifically by the discontinuation of the post-acute care-initiated bundle episodes and by the lack of functional status quality measures. Our comments delineate concerns with BPCI Advanced and offer our recommendations for enhancing the model in future program years. We believe adoption of our proposals will allow BPCI Advanced to properly balance enhancing economic efficiency and coordination of care while concurrently maximizing beneficiaries’ health outcomes and preserving their freedom of choice. AMRPA is the national trade association representing more than 600 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 majority of our members are Medicare participating providers and, on average, Medicare Part A payments represent more than 60 percent of IRH/U revenues.1

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In 2016, IRH/Us served approximately 350,000 Medicare beneficiaries, representing more than 391,000 stays.2 Further, several AMRPA members served as Episode Initiators in BPCI Model 3 and many others participated as care partners under Model 2 (the same model that forms the basis of BPCI Advanced). We commend the Innovation Center for continuing voluntary participation in BPCI Advanced. In order for pilot models to be able to evince best practices in a sustainable and scalable manner, it is critical that these lessons first be demonstrated within health care organizations that have the desire, adequate resources and bandwidth to do so, particularly in a capitated payment environment. AMRPA has a demonstrated track record of supporting CMS in its pursuit of innovations that align incentives to improve the quality and outcomes of beneficiaries’ care. We have engaged with the agency’s various initiatives for care and payment model innovations, providing comments on the EPMs and Comprehensive Care for Joint Replacement (CJR) rules, Health Care Payment Learning and Action Network (HCP LAN) white papers on bundled payments and, most recently, in response to the Innovation Center’s “New Directions” request for information. In 2013, an AMRPA subsidiary submitted a proposal to the Health Care Innovation Awards Round 2 to develop a PAC delivery and payment model under which payments are based on patient characteristics, not site of care, and tied to quality outcomes. Delivering efficient care in a patient-centric and quality-driven manner is core to IRH/Us’ mission and AMRPA is committed to exploring ways to achieve that mission. I. Need for Functional Status Quality Measures The pursuit of value-based care, in which “value” is defined as outcomes divided by cost, can only be as robust as the data in the numerator and the denominator of this ratio. By that token, we think the current BPCI Advanced quality measure set is completely inadequate to address outcomes and should be improved and expanded to mandate inclusion of functional outcome measures that are critically important and meaningful to patients. Any model seeking to deliver patient-centered care needs to include in its quality framework measures that evaluate patient functional status, functional improvement, and the patient’s ability to sustain these improvements over longer periods of time. In rehabilitation, no quality domain is more important than functional outcomes. It entails measuring patients’ gains in

cognitive and physical function and is a fundamental metric of the total impact and value of rehabilitative care. Individuals with higher function are more capable of caring for themselves, more likely to remain in the community, and better equipped to return to work or an active retirement. Patients’ achievement of meaningful gains in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) is highly indicative of their long-term health and well-being, in addition to their future resource use and level of independent living and community integration post injury or illness.3,4,5 Functional status is clearly a driver of resource utilization. The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS), for instance, is predicated upon the causal relationship between a patient’s level of function and their resource use, and sets a precedence for CMS’ recognition of this relationship. Research has also shown functional status to significantly outperform comorbidities as a predictor of a patient’s likelihood for readmissions following hospital discharge.6 Although CMS states it “may look favorably” on BPCI Advanced applications with measures addressing “patient functionality,” we find the noncommittal sentiment of this statement extremely problematic.7 It certainly understates the extraordinary value of functional outcomes measures. A bundled payment model without adequate quality safeguards carries the risk of incentivizing providers to limit costs and stint on care, instead of prioritizing patient well-being, return to function, and quality of life. Several Clinical Episodes in BPCI Advanced involve patients in need of significant hospital-level rehabilitative care, such as stroke, cervical spinal fusion, and back and neck issues. Many stroke and spinal injury patients require intensive rehabilitation services to recover and improve function. Recent clinical guidelines published by the American Heart Association/ American Stroke Association recommend acute hospitallevel care for post-stroke rehabilitation.8 Consistent with this guideline, CMS found that BPCI Model 2 stroke patients experienced functional improvements when treated in IRH/Us compared with relative declines in other PAC settings.9 The human cost and impact of denied medically necessary care is devastating. Unfortunately, it is relatively easy for bundle holders to reduce Medicare Spending Per Beneficiary (MSPB) by denying patient access to timely and intensive rehabilitation services and diverting beneficiaries with the above-cited conditions to less intense levels of postacute care. It is also relatively easy to reduce PAC costs by limiting or restricting the amount, duration, and scope of

1. Medicare Payment Advisory Commission, Report to Congress, Medicare Payment Policy, 267 (Mar. 2018). 2. Id. 3. Arling, G.,Williams, A. R. Cognitive impairment and resource use of nursing home residents a structural equation model. Medical Care , 41 (7), 802–812. 2003 4. Millán-Calenti, J. C., Tubío. Prevalence of functional disability in activities of daily living (ADLs), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality. Archives of Gerontology and Geriatrics, 50 (3), 306–310. 2010. 5. Ramos, L. R., Simoes, E. J., & Albert, M. S. Dependence in activities of daily living and cognitive impairment strongly predicted mortality in older urban residents in Brazil: A 2-year follow-up. Journal of the American Geriatrics Society, 49 (9), 1168–1175. 2001 6. Shih, S., Gerrard, P. Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients. Journal of General Internal Medicine. (30)11, 1688-95. 2015 7. CMS, Bundled Payments for Care Improvement Advanced Request for Applications (RFA). January 8, 2018. 8. American Heart Association/American Stroke Association, Guidelines for Adult Stroke Rehabilitation and Recovery. May 4, 2016. 9. The Lewin Group, CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 3 Evaluation & Monitoring Annual Report (Oct. 2017). 260. Lewin states: “Seven of eight measures using assessment data pointed to a relative decline in functional improvement for BPCI [Model 2 stroke] patients who received post-acute care (PAC) in home health agencies (HHAs) and skilled nursing facilities (SNFs) long enough to have two patient assessments, although only two of the changes from the baseline to intervention period were statistically significant. In contrast, both measures assessing functional limitations for patients treated by inpatient rehabilitation facilities (IRFs) pointed to relative improvements for BPCI patients.”

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rehabilitation services and devices. It would be short-sighted for CMS to focus solely on achieving Medicare savings in the short term when unnecessary disability and lack of function would lead to far greater expenditures in the long term. Less independent living, greater levels of sedentary living, greater dependence on home care, and greater reliance on mobility aids and equipment contribute to high, long-term costs that could be averted through timely, intensive and appropriate rehabilitation services and devices. Medicare reforms should be built upon a solid base that prioritizes patients’ health and functional outcomes above all and certainly values these factors over pure cost-containment. We recommend the Innovation Center recognize the importance of functional outcomes measures by making them mandatory in the BPCI Advanced quality reporting framework starting in Program Year 2. In the interim, CMS should offer financial incentives to providers that elect to report these measures, as done in CJR, in the first Program Year. II. Inclusion of Post-acute Care Providers as Episode Initiators We are disappointed that PAC providers are excluded from being Episode Initiators in BPCI Advanced and that the BPCI Model 3 will effectively be discontinued with the advent of BPCI Advanced. As observed in the current BPCI program, there is significant opportunity for more hospital-level PAC providers such as IRH/Us to be Episode Initiators in voluntary bundled payment models. AMRPA supports PAC delivery and payment reform; it is demonstration pilots like BPCI Advanced that will enable providers to explore more efficient ways to deliver care while maintaining or ideally improving patient outcomes. We believe there is far greater evidentiary basis for expanding PAC-initiated episodes than physician-group practice-initiated (PGP) episodes. Although PGP-initiated episodes account for over half (53 percent) of BPCI Model 2 and Model 3 episodes, CMS has yet to evaluate and assess their impact in the three BPCI Evaluation Reports to date.10 AMRPA appreciates that BPCI Advanced was designed as a vehicle to enable physicians and other eligible clinicians to meet the requirements of the Quality Payment Program (QPP). Nonetheless, it is critical that CMS builds innovation models on a solid base of evidence and understanding of the potential impact to cost savings and, most importantly, patient well-being. CMS cites observed changes in patient mix under BPCI, or “cherry-picking,” as one reason why there is not a PACinitiated bundle in BPCI Advanced. It appears, however, that CMS has already addressed patient selection issues by using a Final Target Price in BPCI Advanced which would be adjusted

for the actual mix of patients admitted under the model. Any perceived challenges associated with PAC-initiated episodes, whether related to development or implementation, cannot be resolved by wholly excluding the sector from participating in bundling initiatives as Episode Initiators. A commitment to aligning provider and patient incentives entails a commitment to engage the full continuum of providers involved in patient care, especially those providers that are most familiar with the post-acute care needs of patients. We urge CMS to include PAC providers as eligible Episode Initiators in BPCI Advanced at least beginning in Program Year 2. Furthermore, the criterion to use Certified Electronic Health Record Technology (CEHRT) poses a restrictive barrier for postacute care providers to participate in BPCI Advanced, even as care partners. PAC settings were excluded from the Electronic Health Record Incentive “Meaningful Use” Program and they lag behind hospitals and physician offices in both EHR and health information exchange (HIE) adoption.12,13 Again, AMRPA appreciates that the BPCI Advanced model was designed to satisfy the definition of an Advanced APM under the QPP. While many IRH/Us have transitioned or are in the process of transitioning to electronic medical records, they may lag behind their acute care hospital counterparts in being able to meet the specified CEHRT criteria established for Advanced APMs. We recommend CMS revise and adapt the CEHRT requirements to allow more PAC providers to be able to participate in BPCI Advanced. III. Patient Choice Unfortunately, there is limited literature to date on the impact of bundled payment models from the patient or caregiver perspective or on their experience of care. What is available however suggests that hospitals may not be satisfactorily transparent or timely in their patient interactions, including communicating to patients that their care will be provided under a bundled environment and what that means, the financial implications therein, and providing a thorough list of the post-discharge care options with meaningful information on the quality of care available.14 The BPCI Evaluation report makes similar observations regarding patient experience of care, finding that patients in several BPCI Model 2 clinical episodes reported significantly worse experiences than their non-BPCI counterparts. These results include: Patients with major joint replacement of the lower extremity were less likely to agree that they were discharged at the right time, and less likely to agree that

10. Id at 435. Lewin writes that “One of the most important advances in this evaluation over the next year will be analyzing the impact of BPCI among the BPCIparticipating PGPs. As of Q3 2015, PGPs accounted for approximately 40% of Model 2 EIs and 13% of Model 3 EIs. The final annual report will include the experience of PGPs and the impact of BPCI on PGP-initiated episode costs and quality. This will help complete the picture of BPCI on multiple outcomes across all types of EIs.” 11. CMS, BPCI Advanced General Frequently Asked Questions (FAQs), January 2018. 12. Dougherty, M. Long-Term And Post-Acute Care Providers Engaged In Health Information Exchange: Final Report to the HHS Office of the Assistant Secretary for Planning and Evaluation. October 29, 2013 13. Wolf, L., Harvell, J., & Jha, A. K. Hospitals ineligible for federal meaningful-use incentives have dismally low rates of adoption of electronic health records. Health Affairs, 31(3), 505-513. March 2012. 14. Joff, T. The Battle Of The Bundle: Lessons From My Mother’s Partial Hip Replacement. Health Affairs, 36(8), 1511-1514. August 2017.

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medical staff clearly explained what follow-up care is needed prior to discharge. Patients with pneumonia were less likely to agree that their care preferences for post-discharge services were considered, or that they understood how to take care of themselves after discharge. Sepsis patients reported significantly worse outcomes on multiple experience of care measures, including: Having always received the appropriate level of care; Patient preferences being taken into account in deciding post-discharge care; Receiving conflicting information from medical staff; and Medical staff always speaking to them in their preferred language.15 For BPCI Advanced to succeed for all parties involved, but especially for patients and their families/caregivers, patients must have full confidence that the decisions being made about their care are indeed in their best interests. It is imperative for CMS to ensure that Medicare beneficiaries retain their freedom of choice when they are placed in a model in which one entity bears financial risk for the total cost of care across multiple provider settings. To address these concerns, we recommend that: CMS require BPCI Advanced participants to notify BPCI Advanced-eligible beneficiaries of their inclusion in the model as early as possible and in each step of the care continuum to the extent possible (though we recognize this may be more administratively challenging for certain urgent/emergent clinical episodes). Episode Initiators should provide BPCI Advanced beneficiaries with a list of all available post-acute care providers (IRH/Us, SNFs, LTCHs, HHAs) in their service area as part of the discharge planning process. The list should distinguish between those providers who are included or not included within any narrow or “preferred provider” networks used by the Episode Initiator for BPCI Advanced purposes. BPCI Advanced beneficiaries should also be informed as to the differences in the quality and intensity of care, capacity, and out-of-pocket costs among their various post-acute care options.

IV. IRH/Us Need Alternative Reimbursement/Pricing and Regulatory Flexibility CMS has encouraged IRH/Us to participate in APMs. However, Medicare reimbursement for rehabilitation hospital services is very rigid, with a fixed per-patient discharge prospective payment system based largely on factors outside of the IRH/U’s control (e.g., principal diagnosis in the preceding hospitalization). In contrast, other PAC providers have a greater degree of control over their Medicare costs, namely through reducing their “units” of utilization in either a per diem payment system (nursing homes) or a fixed-length episodic payment system (home health). Although IRH/Us are encouraged to participate in models in which their services are part of a broader bundle, they are not given sufficient flexibility to control the resources that are utilized under the bundle. To facilitate innovation of care delivery, CMS should grant IRH/Us the flexibility to be responsive to market-based dynamics and not be constrained by an inelastic Medicare fee structure that effectively prices them out of bundled payment programs. In addition to pricing flexibility, CMS and the Innovation Center clearly retain the regulatory authority to waive some or all of the restrictive requirements in the context of these models, and have made similar concessions for other providers. For example, in the context of APMs such as the Medicare Shared Saving Program (MSSP), Next Generation Accountable Care Organizations, BPCI, and CJR, CMS waived significant regulations such as the well-established rule necessitating a minimum three-day inpatient stay prior to covered SNF services.16 Nevertheless, the agency has been unwilling to waive certain regulatory requirements that must be relaxed to facilitate IRH/U participation in these programs. Accordingly, various regulatory requirements should be waived in the context of specific APMs to allow IRH/Us to participate. A. Alternative Reimbursement/Pricing: Because BPCI Advanced holds short-stay acute care hospitals (STACHs) and PGPs responsible for PAC spending, it encourages IRH/Us, and other PAC providers, to produce high-quality outcomes at a reduced cost. Unlike some other PAC providers, however, rehabilitation hospitals are paid on a per-discharge basis for patients. Medicare rules do not allow IRH/ Us to “charge less” in this context. Existing bundling programs therefore incentivize bundle-holders to steer patients away from receiving hospital-level rehabilitation, even when it is imperative to patients’ recovery. CMS’ latest BPCI Evaluation report revealed this very pattern in BPCI Model 2, finding that “numerous” BPCI participants “attempted to reduce

15. The Lewin Group, CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 3 Evaluation & Monitoring Annual Report (Oct. 2017). 97-98. 16. E.g., Centers for Medicare and Medicaid Services, Medicare Shared Savings Program: Skilled Nursing Facility 3-Day Rule Waiver, Guidance Document v. 3 (June 2017). 17. The Lewin Group, CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 3 Evaluation & Monitoring Annual Report (Oct. 2017). ES-6, 82. 18. Id. at ES-5. Per Lewin, institutional PAC settings include IRH/Us, LTCHs, and SNFs. 19. For FY 2018, 43 percent of IRH/Us with available data had negative Medicare margins (below 0 percent) and 52 percent of IRH/Us had margins below 5.0 percent, based on AMRPA analysis of CMS Final Rule FY 2018 Inpatient Rehabilitation Facility Prospective Payment System rate setting files.

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episode payments by reducing institutional PAC use.”17 This has resulted in a dramatic drop in the number of beneficiaries being discharged to institutional PAC settings, with institutional PAC use declining in almost two out of three (61 percent) Model 2 episodes. 18 For IRH/Us to be able to remain a competitive and viable PAC setting within APMs, we recommend that CMS permit IRH/Us to receive reduced reimbursement, a per diem payment, or otherwise offer a discount from the IRF PPS amount if they so choose. Although this likely means that IRH/Us will be paid below cost for treating some patients in these programs, the alternative—that patients are denied access to inpatient rehabilitation altogether—is far worse for Medicare patients and the IRH/U providers who serve them. Since margins are very small or negative for the majority of IRH/Us,19 pricing flexibility must be voluntary, as should all alternative payment and care delivery concepts being tested. Regulatory Flexibility: It is critical for IRH/Us to have sufficient regulatory flexibility to ensure they are able to deliver appropriate care in the bundled payment context. AMRPA recommends that CMS relax the IRH/U intensity of therapy standard for those APM cases for which the provider has elected to receive reduced reimbursement. Specifically, the so-called 3-Hour Rule (which CMS has traditionally interpreted to rigidly require three hours of intensive individualized therapy each day for five days per week that a patient is in an IRH/U) should not apply to cases for which the IRH/U has elected to receive reduced reimbursement under an APM framework. In addition, CMS should afford IRH/Us the option of including patients admitted under an APM as counting towards the IRH/U’s compliance with the 60 Percent Rule. Unlike other hospitals participating in Medicare, in order for IRH/Us to receive payment under their prospective payment system, they must have a patient mix that fits a very specific criterion. Known as the “60 Percent Rule,” the regulation mandates that 60 percent of all IRH/U patients (across all payers) must have diagnoses derived from 13 medical conditions. These 13 conditions are extremely outdated, having been expanded only once since their inception in 1975 (from 10 to 13 conditions), and limit IRH/Us ability to evolve with the ever-changing medical treatment landscape. Innovations and advances in medicine over the past four decades have enabled patients with other serious diagnoses to not only survive acute care hospitalizations, but to also benefit tremendously from the intensive and multidisciplinary rehabilitation program provided in IRH/Us. However, these patients are often denied admission because they do not meet 60 Percent Rule compliance. Hence we ask that CMS grant IRH/Us the option of counting patients admitted under APMs towards their satisfaction of the 60 Percent Rule; this would afford IRH/Us the much-

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needed regulatory flexibility to more fully participate in alternative care and payment delivery models. These approaches are consistent with CMS’ recent emphasis on expanding provider access to APMs, and has been favorably discussed by MedPAC in the context of reforming and advancing Medicare’s postacute care payment systems. CMS has the authority to permit such flexibility, and to waive these bureaucratic requirements without Congressional approval; the agency should do so when promulgating any future models or changes to the current programs. B. Administrative Presumption of Medicare Coverage under APMs: All patients admitted to IRH/Us from upstream hospitals in an APM, regardless of whether the IRH/U is receiving IRF PPS rates or reduced reimbursement, should be presumed to be covered in the rehabilitation hospital setting. Specifically, CMS’ contractors should not be permitted to deny payment for cases treated under APMs based on pre-payment review or post-payment reopening, unless there is evidence of fraud. Episode Initiators are responsible for the cost and quality of care for the patients under their bundle and thus are already held accountable for their post-acute care placement decisions by virtue of the performance metrics and outcomes used in the APM. Hence if a BPCI Advanced STACH or PGP chooses to discharge patients to an IRH/U, they should have full discretion to do so without Medicare contractor interference. CMS should instruct its contractors to respect PAC referrals and admission determinations under APMs such as BPCI Advanced. AMRPA urges CMS to introduce more regulatory flexibility, such as allowing alternative pricing, relaxing siloed regulatory requirements, and presuming IRH/U coverage to allow for IRH/Us to fully participate in CMS efforts to create a more efficient Medicare system. AMRPA members are committed to Medicare innovations that truly place patients back at the center of their care and achieve high-quality and meaningful long-term outcomes for beneficiaries. We welcome the opportunity to meet with the Innovation Center to further discuss our ideas in this area. Thank you for your consideration of these comments as the Innovation Center continues implementation of BPCI Advanced. If you have any questions, do not hesitate to contact Carolyn Zollar, JD, Executive Vice President for Policy Development and Government Relations of AMRPA (202-2231920, czollar@amrpa.org) or Mimi Zhang, Senior Policy and Research Analyst (202-223-1920, mzhang@amrpa.org). Sincerely, Richard Kathrins, PhD Chair, AMRPA Board of Directors President and CEO, Bacharach Institute for Rehabilitation

AHRQ’s Scorecard Shows Decline in Hospital-Acquired Conditions

Highlights: »»

HACs dropped 17 percent from 2010 to 2014, saving $19.9 billion in health care costs and preventing 8,000 deaths.

National efforts to reduce hospital-acquired conditions (HACs) helped prevent an estimated 8,000 deaths and save $2.9 billion between 2014 and 2016, according to an updated report released by the Agency for Healthcare Research and Quality (AHRQ). Conditions such as catheter-associated urinary tract infections (CAUTI), central-line associated bloodstream infections (CLABI), pressure ulcers, surgical site infections and injuries from falls often develop while the patient is in the hospital being treated for something else. CAUTI, pressure ulcers and the incidence of major falls are assessed in the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP). AHRQ is also developing a Quality and Safety Review System that will capture information about HACs and other adverse events directly from electronic health records (EHRs). AHRQ’s National Scorecard on Hospital-Acquired Conditions AHRQ estimates that from 2014 to 2016, 350,000 HACs were avoided and the rate was reduced by 8 percent. Federal experts note that the gains in safety among hospital patients echoed earlier successes, including 2.1 million HACs avoided between 2010 and 2014. HACs overall dropped 17 percent from 2010 to 2014, saving $19.9 billion in health care costs and preventing 87,000 deaths. Updated estimates in AHRQ’s new National Scorecard were based on a new, expanded population set of hospital patients and were calculated despite recent changes in medical

// The data in the new National Scorecard showed that overall events of patient harm decreased in several categories, such as infections and adverse drug events, which dropped 15 percent from 2014 - 2016. AMRPA Magazine / July 2018 33

coding. In addition to developing this measurement strategy, AHRQ developed many of the tools used by hospitals to reduce hospital-acquired conditions. The data in the new National Scorecard showed that overall events of patient harm decreased in several categories, such as infections and adverse drug events, which dropped 15 percent from 2014 - 2016. AHRQ also identified opportunities for further improvement in harm reduction, such as pressure ulcers, which has increased from 2014 -2016. CMS Efforts to Reduce HACs The Centers for Medicare and Medicaid Services (CMS) aims to reduce HACs by 20 percent from 2014 through 2019. Once the 20 percent reduction goal is met, AHRQ projects that during 2015 through 2019 there would be 1.8 million fewer patients with HACs, resulting in 53,000 fewer deaths and saving $19.1 billion in hospital costs from 2015 through 2019. Programs and initiatives such as the Quality Improvement Network – Quality Improvement Organizations (QIN-QIOs), the Hospital Improvement Innovation Networks (HIINs) and the ESRD (End Stage Renal Disease) Network Program provide direct technical assistance and support the spread of evidence-based best practices to reduce HACs via systematic quality improvement work.

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The 16 Hospital Improvement Innovation Networks are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Carolinas Healthcare System Dignity Health Healthcare Association of New York State HealthInsight The Health Research and Educational Trust of the American Hospital Association Health Research and Educational Trust of New Jersey Health Services Advisory Group The Hospital and Healthsystem Association of Pennsylvania Iowa Healthcare Collaborative 1Michigan Health and Hospital Association (MHA) Health Foundation Minnesota Hospital Association Ohio Children’s Hospitals’ Solutions for Patient Safety Ohio Hospital Association Premier, Inc. Vizient, Inc. Washington State Hospital Association

Preliminary data for 2017 are expected within the next year to determine if the reductions seen in 2014-2016 have continued. For the full report, see the AHRQ website.

GAO Conducts Review of Veterans Choice Program, Finds Improvements are Needed to Address Access Challenges

Highlights: GAO found that: »»

Selected veterans experienced lengthy actual wait times for appointments in 2016.

»»

The VHA cannot systematically monitor the timeliness of veterans’ access to Choice Program care because it lacks complete, reliable data.

The Government Accountability Office (GAO) conducted a review of the Veterans Choice Program (Choice Program) where eligible veterans may receive care from community providers when it is not readily accessible at Veterans’ Health Administration (VHA) medical facilities. Many inpatient rehabilitation hospitals and units participate as community providers through the Choice Program and other programs to provide services to veterans and their families. The Choice Program was created in 2014 to address longstanding challenges with veterans’ access to care at VHA medical facilities. The Joint Explanatory Statement for the Consolidated Appropriations Act of 2016 included provisions for GAO to review veterans’ access to care through the Choice Program. The report examines: The Department of Veterans Affairs (VA) appointment scheduling process; The timeliness of appointments and the information VHA uses to monitor veterans’ access; and The factors that have adversely affected veterans’ access and the steps VA and VHA have taken to address them for VA’s future community care program. GAO’s Review The Department of Veterans Affairs (VA) uses two contractors—or third party administrators (TPA)—to schedule most veterans’ Choice Program appointments after receiving referrals from VA medical centers (VAMC). GAO reviewed applicable laws and regulations, VA’s TPA contracts, and relevant VHA policies and guidance. GAO also selected six of 170 VAMCs and manually reviewed a random sample of 196 Choice Program authorizations.

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The authorizations were created for veterans who were referred to the program between January and April 2016. These included 55 referrals for routine care, 53 for urgent care and 88 that the TPAs returned without scheduling appointments. GAO also looked at wait times for a nationwide sample of about 5,000 Choice Program authorizations that were created for selected services between July and September 2016. GAO’s Findings GAO found that: Veterans who are referred to the Choice Program for routine care because services are not available at VA in a timely manner could potentially wait up to 70 days for care. This is not consistent with the statutory requirement that veterans receive Choice Program care within 30 days of their clinically indicated date, which is the soonest date that it would be appropriate for the veteran to receive care, according to a VHA clinician. Without designing appointment scheduling processes that are consistent with this requirement, VA lacks assurance that veterans will receive Choice Program care in a timely manner. Selected veterans experienced lengthy actual wait times for appointments in 2016, after manually reviewing separate samples of Choice Program authorizations. For example, when GAO analyzed 55 routine care authorizations that were created between January and April 2016, it found that the process took at least 64 calendar days, on average. When VHA analyzed about 5,000 authorizations created between July and September 2016, it took an average of 51 calendar days for veterans to receive care. The VHA cannot systematically monitor the timeliness of veterans’ access to Choice Program care because it lacks complete, reliable data to do so. The data limitations GAO identified were: (1) A lack of data on the timeliness of referring and opting veterans in to the program. The data VHA uses to monitor the timeliness of Choice Program appointments do not capture the time it takes VAMCs to prepare veterans’ referrals and send them to the TPAs, nor do they capture the time spent by the TPAs in accepting VAMCs’ referrals and opting veterans in to the Choice Program. VHA has implemented an interim solution to monitor overall wait times that relies on VAMC staff consistently and accurately entering unique identification numbers on VHA clinicians’ requests for care and on Choice Program referrals, a process that GAO says is prone to error. (2) Inaccuracy of clinically indicated dates. Clinically indicated dates (that are used to measure the timeliness of care) are sometimes changed by VAMC staff before they send Choice Program 36 AMRPA Magazine / July 2018

// While the current Choice Program will soon end, VA anticipates that veterans will continue to receive community care under a similar program that VA plans to implement, which will consolidate the Choice Program and other VA community care programs. referrals to the TPAs. VAMC staff entered later clinically indicated dates on referrals for about 23 percent of the 196 authorizations it reviewed. It is unclear if VAMC staff mistakenly entered incorrect dates manually, or if they inappropriately entered later dates when the VAMC was delayed in contacting the veteran, compiling relevant clinical information, and sending the referral to the TPA. (3) Unreliable data on the timeliness of urgent care. VAMCs and TPAs do not always categorize Choice Program referrals and authorizations in accordance with the contractual definition for urgent care. According to the contracts, a referral is to be marked as “urgent,” and an appointment is to take place within two days of the TPA accepting it, when a VHA clinician has determined that the needed care is essential to evaluate and stabilize the veteran’s condition, and if delayed would likely result in unacceptable morbidity or pain. GAO reviewed a sample of 53 urgent care authorizations and determined that about 28 percent of the authorizations were originally marked as routine care authorizations but were changed to urgent by VAMC or TPA staff, in an effort to administratively expedite appointment scheduling. Without complete, reliable data, VHA cannot determine whether the Choice Program has helped to achieve the goal of alleviating veterans’ wait times for care. Numerous factors adversely affected veterans’ access to care through the Choice Program. These factors include: (1) administrative burden caused by complexities of referral and appointment scheduling processes, (2) poor communication between VHA and its VAMCs, and (3) inadequacies in the networks of community providers established by the TPAs, including an insufficient number, mix, or geographic distribution of community providers.

GAO concluded that although the VA and VHA have taken numerous actions throughout the Choice Program’s operation that are intended to help address these factors, access issues have not been fully resolved. For example, to help address administrative burden and improve the process of coordinating veterans’ Choice Program care, VA established a secure e-mail system and a mechanism for TPAs and community providers to remotely access veterans’ VA electronic health records. However, these mechanisms only facilitate a one-way transfer of necessary information, they do not provide a means by which VAMCs or veterans can view the TPAs’ step-by-step progress in scheduling appointments or electronically receive medical documentation associated with Choice Program appointments. While the current Choice Program will soon end, VA anticipates that veterans will continue to receive community care under a similar program that VA plans to implement, which will consolidate the Choice Program and other VA community care programs. Incorporating lessons learned from the Choice Program into the implementation and administration of the new program could help VHA avoid similar challenges. GAO’s Recommendations For VA’s future consolidated community care program, GAO made 10 recommendations, which include: Establishing an achievable wait-time goal for the community care program that will permit VHA to monitor whether veterans are receiving care within time frames that are comparable to the amount of time they would otherwise wait for care at VHA medical facilities;

Designing an appointment scheduling process that (1) is consistent with the wait-time goal and (2) sets forth time frames within which veterans’ referrals must be processed, appointments must be scheduled, and appointments must occur; Implementing mechanisms to: allow VHA to systematically monitor the amount of time taken to: Prepare referrals, schedule appointments, and complete appointments; Prevent veterans’ clinically indicated dates from being modified by individuals other than VHA clinicians; and Separate clinically urgent referrals and authorizations from those for which the VAMC or the TPA has decided to expedite appointment scheduling for administrative reasons; and Establishing a system that will help facilitate seamless, efficient care coordination and exchanges of information among VAMCs, VHA clinicians, TPAs, community providers, and veterans. The VA agreed with all but one of GAO’s recommendations, which was to separate clinically urgent referrals from those that are administratively expedited. GAO maintains that implementing this recommendation will help improve future monitoring of urgent care timeliness for reasons explained in the report. For the complete report, see the GAO website.

AMRPA Magazine / July 2018 37

Study Examines Health Insurance and Disparities in Mortality Among Older Survivors of Critical Illness

Highlights: »»

Mortality in the first year after critical illness was higher among older adults with Medicaid compared to those with Medicare especially among those discharged to SNFs.

A new study has found that seniors who are insured by Medicaid are less likely to survive in a nursing home after an intensive care unit (ICU) stay than seniors covered by Medicare and commercial insurance. The study “Health Insurance and Disparities in Mortality Among Older Survivors of Critical Illness,” was published in the American Journal of Respiratory and Clinical Care Medicine. The study states that access to care and outcomes for several diseases have been shown to differ by whether patients aged 65 years and older have additional commercial or Medicaid insurance coverage. It is unknown whether mortality differs by type of insurance coverage for the approximate 1.5 million older Americans who annually survive a hospitalization necessitating intensive care. The study authors sought to determine whether different types of insurance status are independently associated with a higher one-year mortality rate among older survivors of critical illness. Methods The researchers used the New York Statewide Planning and Research Cooperative System (SPARCS) database and American Hospital Association Annual Survey to examine post-discharge mortality of New Yorkers age 65 and older who had their first hospitalization in intensive care, and survived while in the hospital. They examined 339,261 New York state cases between 2010 and 2014. Results The primary outcome was mortality in the first year after hospital discharge. Of the 339,261 survivors of critical illness, 20 percent died within one year of hospital discharge. Compared to those with Medicare and commercial insurance, those with Medicare alone had no difference in one-year mortality, and those with Medicaid had a 7 percent higher one-year mortality rate. Compared to whites, blacks had a similar one-year mortality rate, while Hispanic ethnicity was associated with better one-year survival. The association between insurance status and mortality

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only varied among whites when the analysis was stratified by race. Whites with Medicaid had a 9 percent higher one-year mortality rate when compared to those with Medicare and commercial insurance. Analyses stratified by discharge location showed that the oneyear adjusted mortality rate did not vary by insurance status, Medicare alone and Medicaid, for those discharged home, but was substantially greater for Medicaid recipients discharged to skilled nursing facilities (SNFs).

National Leadership Excellence Award

The authors concluded that mortality in the first year after critical illness was higher among older adults with Medicaid insurance compared to those with Medicare and additional commercial insurance, especially among those discharged to SNFs. According to the authors, these findings should prompt future investigations into care disparities at SNFs that may mediate the higher mortality rates observed among these poor older survivors of critical illness. For the study, see the American Journal of Respiratory and Clinical Care Medicine.

Call for Nominations Deadline is July 30, 2018 www.amrpa.org

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AMRPA Magazine / July 2018 39

Comprehensive Care Physician Model Improves Care, Lowers Hospitalization, Study Finds

Highlights: »»

The program reduced hospitalization and expense for high risk patients.

»»

The CCP model was both preferred by patients and economically beneficial in terms of reducing health care utilization.

Patients who need frequent hospitalization account for a disproportionate amount of health care spending in the United States. In 2012, the University of Chicago Medicine began enrolling patients in a clinical trial designed to test ways to reduce such hospital stays. The study was funded by the Health Care Innovation Award from the Center for Medicare and Medicaid Innovation (CMMI). The study was designed to determine whether doctors who focus their practices on the care of patients in and out of the hospital, known as comprehensive care physicians (CCPs), could improve care while reducing hospitalization for a highly vulnerable set of patients at high risk for being hospitalized. Patients with chronic health problems enrolled in the study from November 2012 to June 2016. Most of them had at least one hospital stay in the previous year and all of the patients were covered by Medicare.

// Over the course of the pilot study, the model resulted in improved continuity of patient care, especially during and after a hospital stay, and strengthened the bond between doctor and patient.

The model was designed to provide better care at lower cost. Over the course of the pilot study, the model resulted in improved continuity of patient care, especially during and after a hospital stay, and strengthened the bond between doctor and patient.

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Model Design The core element of the CCP model is that the same physician provides care for patients in the clinic as well as in the hospital, with a few CCPs even making house calls. The CCPs also lead a team of nurse practitioners, social workers, care coordinators and other specialists selected for their ability to address the needs of high-risk patients. Each physician carries a panel of approximately 200 patients at a time, and serves as their primary care physician during clinic visits and supervising their care whenever they are hospitalized. The model is built upon 15 years of research by study director David Meltzer, MD, PhD, professor of medicine at the University of Chicago and chief of hospital medicine, and colleagues, on the changing medical workforce in the United States. Half of the patients in the study were assigned to “standard care.” They connected with a hospital-based primary care physician who saw patients as needed in the clinic, but did not directly take care of them if they were admitted to the hospital. The other half were assigned to one of five CCPs, who saw them during clinic visits and also cared for them in the hospital. The trial enrolled patients who are predicted to spend an average of 10 days a year in the hospital. Many of these patients have chronic diseases and others are geriatric patients living in residence homes or patients with renal disease requiring regular dialysis treatment.

Results The CCP model has been preferred by patients and is economically beneficial in terms of reducing health care utilization. The university’s standard care physicians scored in the 80th percentile nationally, but the CCP doctors were in the 95th percentile. They also were ranked higher by patients dealing with mental health issues. This program “may improve patient experience and health status while substantially reducing utilization for patients at increased risk for hospitalization,” the study authors conclude. “The CCP model warrants further exploration through efforts to implement it in additional settings and rigorously evaluate its effects on outcomes and costs.” The next step is an expanded program, the Comprehensive Care, Community and Culture Program (C4P), designed to reduce the unmet social needs of economically and socially disadvantaged patients. The program has already enrolled about 400 participants. For more information, see the University of Chicago Medicine website.

AMRPA Magazine / July 2018 41

Latest Research Findings

AHRQ Disseminates Surgical Site Infection Prevention Guidelines According to data from the Agency for Healthcare Research and Quality (AHRQ), more than 10 million patients undergo surgical procedures as inpatients each year, accounting for over onefourth of all hospital stays. AHRQâ&#x20AC;&#x2122;s latest Patient Safety Primer provides an overview of the prevention of surgical site infections (SSI), with a focus on system-level interventions. The most common types of inpatient surgical procedures include orthopedic procedures (hip and knee replacement, hip fracture repair), neurosurgical procedures (spinal fusion and laminectomy), and intraabdominal procedures (cholecystectomy and colorectal resections). Most orthopedic surgery patients receive post-discharge care in post-acute care in inpatient rehabilitation hospitals or other settings. Increasing numbers of patients also undergo surgery at ambulatory surgery centers (ASCs), facilities specifically designed for certain types of surgery after which the patient can be discharged home directly. Surgical Site Infections Surgical site infection (SSI) is an infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure, or within 90 days if prosthetic material is implanted at surgery. It is among the most common preventable complication after surgery. SSIs occur in 2 percent to 4 percent of all patients undergoing inpatient surgical procedures.

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Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery. They are the leading cause of readmissions to the hospital following surgery, and for approximately 3 percent of patients who contract an SSI, it can be fatal. Although SSIs are less common following ambulatory surgery than after inpatient procedures, they are a frequent source of morbidity in these patients as well.

Risk Factors Risk factors for SSI include patient factors (such as age, tobacco use, diabetes and malnutrition) and procedure-specific risk factors (including emergency surgery and the degree of bacterial contamination of the surgical wound at the time of the procedure). While many of these risk factors are not modifiable, the majority of SSIs are considered preventable, and recent advances have shed light on how hospitals can systematically prevent these infections. SSI Prevention The CDC's National Healthcare Safety Network (NHSN) has developed standards for SSI measurement, and these definitions are also used by the National Surgical Quality Improvement Program (NSQIP) Both the NHSN and NSQIP definitions are widely used for both quality improvement and research purposes. The CDC has also developed guidelines (last updated in 2017) summarizing the evidence for clinical interventions to prevent SSI; the World Health Organization issued SSI prevention guidelines in 2016. Adherence to these clinical standards (for example, administration of appropriate antimicrobial prophylaxis) is routinely tracked in the form of process measures that, if adhered to, should reduce the incidence of SSI. However, as with many other quality issues, implementing the recommended methods as standard practice and sustaining their use has been challenging. Many organizations have been able to achieve sustained reductions in SSIs, and AHRQ has led key efforts to encourage dissemination and implementation of SSI prevention strategies. These best practices include improving safety culture, the use of robust data tracking and feedback mechanisms, and utilizing checklists or evidence-based bundles. Comprehensive Unit-Based Safety Program The comprehensive unit-based safety program (CUSP) has been demonstrated to be instrumental in driving reductions in SSI. CUSP emphasizes improving safety culture through a continuous process of identifying and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. The AHRQ Safety Program for Surgery used the CUSP model and implementation science approaches to improve adherence to evidence-based SSI prevention practices in 197 hospitals. Participating hospitals implemented the CUSP using either the NHSN or NSQIP methods and participated in collaborative learning experiences. The intervention was associated with

a significant reduction in SSI rates at participating hospitals, accompanied by an improvement in perceived safety culture. The organizational culture, such as active engagement from senior leadership and creation of a nonpunitive environment, were also crucial success factors. AHRQ has created toolkits for both hospitals and ambulatory surgery centers that contain guides and instructional modules for implementing CUSP principles and methods for promoting safe surgery. Surgical Safety Checklists Surgical safety checklists are tools to standardize safety assessment and improve teamwork and communication in surgical care, and also generally include specific steps to reduce SSI risk (for example, ensuring that preoperative antimicrobial prophylaxis has been administered at the appropriate time). Although checklists are effective at preventing intraoperative and postoperative complications, real-world implementation remains a challenge, and there is no clear evidence that checklists alone can prevent SSIs. The AHRQ Safety Program for Surgery used a multicomponent intervention designed to improve safety culture surrounding SSI prevention. Another project, the AHRQ Safety Program for Improving Surgical Care and Recovery is an ongoing collaborative program to enhance the recovery of surgical patients. This project aims to address multiple types of patient harm, including SSI and other harms, in an integrated way throughout the surgical care pathway. AHRQ states that SSI prevention is a high-priority goal for health care organizations. The Joint Commission includes use of guidelines to prevent SSI as one of its National Patient Safety Goals for hospitals and ambulatory surgery centers. The Centers for Medicare and Medicaid Services (CMS) require hospitals to report SSI rates, which are publicly disseminated on its Hospital Compare website, along with other surgical quality measures. Efforts to prevent surgical site infections have been effective. Data from AHRQ's Partnership for Patients initiative indicates that the national rate of SSI decreased by 16 percent between 2010 and 2015, translating into significant benefits for patients (including many lives saved), as well as significant cost savings. For more information, see AHRQ Patient Safety Primer, Surgical Site Infections, June 2018.

AMRPA Magazine / July 2018 43

Study Finds 2.6 Percent Mortality Rate Among Children Hospitalized for Stroke Childhood ischemic strokes affect 1.2 to 2.4 per 100,000 children per year in developed countries. Although deaths from ischemic and other types of stroke appear to have declined, stroke remains among the top 10 causes of death among children in the United States. A study, "Mortality After Pediatric Arterial Ischemic Stroke," published in the journal Pediatrics found that 2.6 percent of infants and children hospitalized for stroke die in the hospital. The retrospective study included 915 infants younger than one month and 2,273 children aged one month to 18 years who were stroke patients at 87 hospitals in 24 countries. The study examined ischemic stroke, which is caused by blood clots and is the most common type. The study authors were Lauren A. Beslow, MD, of the Children's Hospital of Philadelphia and coauthor Loyola Medicine neurologist JosĂŠ Biller, MD. The study found that during their hospitalizations for ischemic stroke, 1.5 percent of the infants and 3.1 percent of the children died, with an overall mortality rate of 2.6 percent. Researchers classified the causes of death as stroke alone, a combination of an underlying disease and stroke, or simply an underlying disease. Nearly two-thirds (65 percent) of hospital deaths with a known cause were related to the stroke and/or subsequent deficits. Risk factors for dying in the hospital included congenital heart disease and having a severe type of ischemic stroke known as "posterior plus anterior circulation."

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Hispanic ethnicity was also associated with higher mortality, and the study authors indicated that the reason for the higher rate was not known, but black infants and children were not at higher risk of dying. Future studies "should explore whether ethnic differences in mortality rates are related to disparities in care," researchers wrote. The study also found that infants and children who had seizures had a lower stroke mortality rate. The reason may be that infants who present with seizures might be diagnosed and treated more quickly for their strokes, researchers wrote. Researchers note that improved stroke recognition, earlier supportive care, more rapid intervention and neuroprotective treatments "are critical for decreasing mortality after stroke in the pediatric population." For the study, see Mortality After Pediatric Arterial Ischemic Stroke, in Pediatrics, April 2018.

To ensure AMRPA members are active participants in shaping their federal representation in Congress, we are continuing to provide updates on upcoming Congressional elections. Below you’ll find information on primaries taking place in August and September, as well as online resources where you can find additional information on voting and your Congressional representatives. The following states will be holding primary elections in August, for a total of 14 primary elections:

Tennessee – August 2, 2018 Nine House seats are up for election: seven incumbents and two opens seats. One Senate seat is up for election.

Kansas – August 7, 2018 There are four House seats in the delegation: three incumbents and one open seat. No Senate seats are up for election.

Michigan – August 7, 2018 There are 14 House seats up for election: 12 incumbents and two open seats. One Senate seat is up for election.

Missouri – August 7, 2018 Eight House seats are up for election. All incumbents are running for reelection. One Senate seat is up for election.

Washington – August 7, 2018 There are ten House seats in the delegation: nine incumbents and one open seat. One Senate seat is up for election.

Hawaii – August 11, 2018 Two House seats are up for election: one incumbent and one open seat. One Senate seat is up for election.

Connecticut – August 14, 2018 Five House seats are up for election: four incumbents and one open seat. One Senate seat is up for election.

Minnesota – August 14, 2018 There are eight House seats up for election: six incumbents and two open seats. One Senate seat is up for election.

Vermont – August 14, 2018 There is one House seat in the delegation. The incumbent is running for reelection. One Senate seat is up for election.

Wisconsin – August 14, 2018 Eight House seats are up for election: seven incumbents and one open seat. One Senate seat is up for election.

Alaska – August 21, 2018 There is one House seat in the delegation. The incumbent is running for reelection. No Senate seats are up for election.

Wyoming – August 21, 2018 There is one House seat up for election. The incumbent is running for reelection. There is one Senate seat up for election.

Arizona – August 28, 2018 Nine House seats are up for election: six incumbents and three open seats. One Senate seat is up for election.

Florida – August 28, 2018 There are 27 House seats in the delegation: 23 incumbents and four open seats. There is one Senate seat up for election.

AMRPA Magazine / July 2018 45

The following states will be holding primary elections in September, for a total of five primary elections:

Massachusetts – September 4, 2018 Nine House seats are up for election: eight incumbents and one open seat. One Senate seat is up for election.

Delaware – September 6, 2018 There is one House seat up for election. The incumbent is running for reelection. One Senate seat is up for election.

Be sure to visit the AMRPA website for more up-todate election information. You can find the ‘2018 Congressional Elections’ page under the ‘Advocacy’ tab on www.amrpa.org. If you have any questions or feedback, contact Catherine Beal at cbeal@amrpa.org or (202) 860-1006. For more information on your federal representatives, visit the following websites:

New Hampshire – September 11, 2018

Find your House representative here: www.house.gov/ representatives/find-your-representative and Senators here: www.senate.gov/general/contact_information/ senators_cfm.cfm.

There are two House seats in the delegation: one incumbent and one open seat. No Senate seats are up for election.

For more voting information, and to find out if you are registered, visit: www.usa.gov/voting.

Rhode Island – September 12, 2018 Two House seats are up for election. Both incumbents are running for reelection. One Senate seat is up for election.

New York – September 13, 2018 There are 27 House seats up for election: 26 incumbents and one open seat. One Senate seat is up for election.

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