AMRPA Magazine June 2018

June 2018 • Vol. 21, No. 6

Member Engagement and FY 2019 Proposed IRF Rule

June 2018 • Vol. 21, No. 6

The official publication of the American Medical Rehabilitation Providers Association AMRPA Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Manager Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA Mimi Zhang Senior Policy and Research Analyst, AMRPA Patricia Sullivan AMRPA Senior Editor Lovelyn Robinson AMRPA Researcher and Editor Brian McGowan and Shirley Soda AMRPA Design and Layout

AMRPA Magazine, Volume 21, Number 6 AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA).

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

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AMRPA Magazine / June 2018

Table of Contents Letter from the Chair

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Legislative Update

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Rehabilitation and Disability in China: A First-Hand Account

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Identifying Tiering Comorbidities

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FY 2019 IRF PPS Proposed Rule Seeks to Use IMPACT Act Function Data for Payment Purposes, Includes Other "Burden Reduction" Proposals

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CMS Releases IPPS and LTCH Proposed Rule for 2019; Lifts Restrictions on Excluded Units

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FY2019 SNF PPS Rule Proposes Major Change to Nursing Home Payment System

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MedPAC Develops Uniform PAC Outcomes Measures, Turns Attention to PAC Value-based Purchasing

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Coalition to Preserve Rehabilitation Urges CMS to Increase Its Oversight of Prior Authorization Under the Medicare Advantage Program

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New Interim Final Rule to Provide Relief for Providers Through Increased Fee Schedule Rates

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Medicare Managed Care Pay to Increase by More Than 3 Percent in 2019

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GAO Issues Report on CMS' Innovation Center Implementation and Performance

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Health Care Spending Rises as Americans Use Less Care, HCCI Says

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Latest Research Findings

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Letter from the Chair

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

Member Engagement and the FY 2018 Proposed IRF Rule In late April, the Centers for Medicare and Medicaid Services (CMS) issued its FY 2019 Proposed Rule for IRFs and other health care sectors. What is always remarkable to me is the process that AMRPA goes through to respond to this rule. The process may seem like a mystery, but for those who take an active role in many of the workgroups, it is annual ritual. Participants have a responsibility to ensure that the rule is transparent, fair, justifiable and accurate. At this point I take the process for granted, not thinking about the who, what, why and the effort that goes into responding to the rule. Know that all these efforts have been effective in changing some of the past CMS Proposed Rules.

Just to give those not involved a sense of the scope of involvement, AMRPA members and staff work under the direction of the Legislative and Regulatory Committee to provide clinical, administrative, operational and financial input into the proposed rule. The workgroups and committees responsible for this review include the Finance and Labor, CMG and Length of Stay and coverage criteria workgroups, and the Quality Committee. Given the changes suggested in this year’s rule, we created new workgroups that included FIM and revised CMG weights and length of stay, use of physician extenders, and an interoperability request for information.

The groups use many sources of evidence; a distinct advantage to our association’s work is ready access to industry-wide data from eRehabData®.

To add to the workload of our dedicated staff, we also need to carefully track other rules such as those covering LTACHs and SNFs. Close to 100 individuals from all sectors of our field, including freestanding IRFs, units, not-for-profits, for-profits, and academic inpatient rehab hospitals come together to provide input. The work products from these various groups and committees are then compiled by association staff and outside council.

// AMRPA members and staff work under the direction of the Legislative and Regulatory Committee to provide clinical, administrative, operational and financial input into the proposed rule.

Our members are dedicated, knowledgeable and willing to share their valuable time and resources. This is a unique association in that our positions and recommendations are driven by our members with the support of a well-seasoned and knowledgeable staff in our Washington office. If you or your staff missed an opportunity to join one of these workgroups, we hope that you will consider joining us next year to ensure that your voice and experience is registered as we move forward. Regardless of what CMS’s final rule dictates, we can feel comfortable that once again we spoke with one voice and provided our best feedback on the proposed rule.

AMRPA Magazine / June 2018

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FAIR FUND Fund for Access to Inpatient Rehabilitation

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AMRPA Magazine / June 2018

Legislative Update

Appropriators Begin Consideration of Individual Funding Measures for FY 2019 Appropriators are hopeful they can move at least a handful of individual Fiscal Year (FY) 2019 appropriations measures through both chambers of Congress this summer.

House Republicans have discussed the possibility of “pre-conferencing” with the Senate on a number of less controversial spending bills, such as the Legislative Branch, Energy-Water, and Military Construction-VA measures. It is unclear how House Republicans plan to package the bills for FY 2019.

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

Highlights: »»

On May 8, President Trump sent a rescissions proposal to Congress that would cut $15.4 billion from current federal spending, based on concerns with overspending.

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CMS released several annual payment rules, including the FY 2019 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Proposed Rule.

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House Veterans’ Affairs Committee approved legislation to extend the Veteran’s Choice Program, including provisions that aim to improve provider payments and collections.

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Congress continues to move forward with the development of and consideration of legislation aimed to combat the opioid epidemic.

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President Trump, with the support of HHS Secretary Azar, is expected to announce aggressive proposals aimed at reducing the high cost of prescription drugs.

In the Senate, meanwhile, Appropriations Committee Chair Richard Shelby (R-AL) announced that both sides had reached a preliminary agreement on an open amendment process for spending bills. Leadership hopes this change will limit time-consuming cloture votes that require 60 votes. The Appropriations Committee expects to mark-up bills in May and send at least some of them to the floor in June.

President Aims to Cut $15.4 Billion in Federal Spending On April 8, President Trump submitted a $15.4 billion “rescissions” package to Congress, in reaction to concerns of overspending in the $1.3 trillion Omnibus appropriations package. Almost half of the spending cut proposals come from unspent Children’s Health Insurance Program funds ($7 billion). The proposal also rescinds $800 million “in excess” from the Center for Medicare and Medicaid Innovation for FY 2011 to 2019. By law, Congress has 45 calendar days to act on the package. However, if the relevant committees have not acted within 25 days, a member of either the House or Senate that supports the rescissions measure may seek to discharge the package from committee with the support of at least one-fifth of their chamber.

House Majority Leader Kevin McCarthy (R-CA) has endorsed the package, and it is expected to pass the House easily. However, passage in the Senate is less clear.

House and Senate Committees Move Legislation Addressing Opioid Epidemic On April 24, the Senate Health, Education, Labor and Pensions (HELP) Committee voted 23-0 to advance bipartisan opioid legislation. The Opioid Crisis Response Act (S. 2680) includes 40 bills from 38 senators, including proposals to accelerate research on non-addictive pain medications, support state prescription drug monitoring programs, expand access to substance use disorder treatment services, and improve detection of illegal imported drugs. HELP Committee Chair Lamar Alexander (R-TN) suggested the full Senate could take up the bill sometime this summer. The committee agreed to several amendments during the markup, but rejected an amendment offered by Sen. Bernie Sanders (I-VT) to impose civil penalties on companies that market opioid products as non-addictive.

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In the House, the Energy and Commerce Committee advanced its own package of opioid abuse legislation. On April 25, the panel’s Health Subcommittee voted to pass 56 bills related to the opioid crisis, and the full committee has approved many of the measures for consideration by the House of Representatives. It is expected that the Senate Finance and House Ways and Means Committees will also weigh in with their own legislative proposals to combat the opioid epidemic.

A final opioid package could receive a floor vote in early June, with the goal of sending legislation to the president by the August recess.

medications. The blueprint reiterates proposals from the president’s FY19 Budget to lower drug prices and includes reforms to Medicare Part B and D, as well as changes to 340B drug payments. The Department of Health and Human Services (HHS) is expected to take a range of immediate actions to implement the president’s blueprint. Proposals reportedly under consideration include allowing states to create and negotiate their own Medicaid formulary and related price discounts; moving Part B drugs to Part D; passing rebates from pharmacy benefit managers on to seniors in Medicare Part D; and adopting 340B reforms.

House Health Committee Activity The House Ways and Means Committee Health Subcommittee held a hearing on April 26 to examine innovation in health care. Much of the hearing focused on technology, especially health information sharing and telemedicine, but members also discussed value-based payment models and the importance of care coordination.

Consistent with the president’s emphasis, FDA Commissioner Scott Gottlieb and HHS Secretary Alex Azar also have repeatedly called for action to address rising drug prices. CMS Administrator Seema Verma has indicated interest in exploring whether sufficient legal authority exists to allow state Medicaid agencies to limit Medicaid prescription drug formularies, in order to give states greater leverage to secure price discounts from drug manufacturers.

On May 8, the Health Subcommittee held a hearing on the Medicare Advantage program. The witnesses and subcommittee members mostly reflected on how MA plans prove that choice and competition help keep health care costs under control, although Ranking Member Sandy Levin (D-MI) noted that many beneficiaries are in plans with narrow provider networks. He emphasized the need to provide complete and accurate plan information to beneficiaries. AMPRA is submitting a statement for the hearing record.

House VA Committee Marks Up Choice Program Legislation On May 8, the House Veterans’ Affairs Committee Chair Phil Roe (R-TN) held a hearing to mark-up H.R. 5674, the Department of Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks, or “VA MISSION Act.” The bill would consolidate community-based care programs of the Department of Veterans Affairs (VA) under the Veterans Choice Program and provide $5.2 billion to fund the current Choice Program until the new program is implemented next year. It also includes provisions related to VA assets and infrastructure and recruitment of health care professionals. While there were several amendments offered to the Veterans Choice bill, Chair Roe stated that as a part of the agreed upon negotiations none would be accepted. ‎The bill passed out of committee with a vote of 20-2. The chair will request that the bill be renamed in honor of Sen. John McCain and Rep. Sam Johnson.

President Trump Outlines Drug Pricing Proposals President Trump has indicated he will announce a series of initiatives to reduce drug prices in the near future. The president’s announcement of the administration’s plan has been scheduled and postponed several times. The White House announced its blueprint on May 11. The proposal focuses on high list prices by manufacturers; rising out of pocket costs; foreign government “free-riding” off of American innovation; and rules preventing private plans from negotiating drug prices for seniors, especially for high-cost

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CMS Releases Several Proposed Payment Regulations On April 24, CMS released the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-term Care Hospital (LTCH) Prospective Payment System (PPS) and Proposed Policy Changes and Fiscal Year (FY) 2019 Rates. CMS proposes to increase Medicare payments to acutecare hospitals by 3.4 percent, a $4 billion increase in 2019. The rule makes major changes to the “Meaningful Use” program by providing hospitals with more flexibility in how they use electronic health records. The rule proposes to change the program name to “Promoting Interoperability,” with a new focus on interoperability between patients and their providers.

CMS also plans to require hospitals to publically post the prices of their services online in order to offer patients greater price transparency for inpatient care. The proposed rule also aims to eliminate requirements for hospitals to report some measures considered overly burdensome or duplicative.

On April 27, CMS released the FY 2019 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Proposed Rule. For the FY 2019 proposed changes, CMS estimates the results will be a $75 million increase in IRF PPS payments for FY 2019, which is a net revenue increase of approximately 0.9 percent. The provision of greatest concern is CMS’ proposal to remove the Functional Independence Measure (FIM) Instrument from the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI) in FY 2020. In its place, CMS proposes to use the function data collected pursuant to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), which the agency refers to as the data items from the Quality Indicators section of the IRF PAI, as the new basis of the Case Mix Groups (CMGs) for the IRF PPS. AMRPA is working to analyze the policy’s impact and draft detailed comments. AMRPA anticipates a need for stepped up advocacy and member engagement to register concerns about the rulemaking to members of Congress and CMS. On April 27, CMS released the FY 2019 Skilled Nursing Facility

(SNF) PPS Proposed Rule. The rule proposes to increase SNF payments by an estimated $850 million, resulting from the FY 2019 SNF market basket update required to be 2.4 percent by the Bipartisan Budget Act of 2018. The rule moves forward with replacing the existing case-mix model, the Resident Classification System Version I (RCS-I), with the new SNF Patient-Driven Payment Model (PDPM), designed to reduce complexity and improve the incentives to treat the needs of the whole patient.

On April 27, CMS issued the FY 2019 Hospice Wage Index and Payment Rate Update Proposed Rule, and is proposing an increase of 1.8 percent ($340 million) for hospice payments for FY 2019. CMS plans to implement Section 51006 of the Bipartisan Budget Act of 2018 so that physician assistants are now recognized as attending physicians for Medicare hospice beneficiaries.

Notably, all the rules include an RFI seeking feedback on the possibility of revising the Conditions of Participation (CoPs) related to interoperability as a way to expand the electronic sharing of data by providers. Specifically, the agency might consider revisions to the current CMS CoPs for hospitals such as: requiring that hospitals transferring medically necessary information to another facility upon a patient transfer or discharge do so electronically; requiring that hospitals electronically send required discharge information to a community provider via electronic means if possible and if a community provider can be identified; and requiring that hospitals make certain information available to patients or a specified third-party application (for example, required discharge instructions) via electronic means if requested.

We are looking ahead to several busy months and want your active engagement on issues of critical concern to the field!

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AMRPA Magazine / June 2018

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Rehabilitation and Disability in China: A First-Hand Account

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

I recently had the honor of participating in a United States delegation to China, part of an annual dialogue called the U.S.-China Coordination Meeting on Disability the two countries have been engaged in for the past four years. Disability is one of the few human rights topics the Chinese are willing to meaningfully discuss with our country of late. The delegation was orchestrated by the U.S. State Department’s Division on Democracy, Human Rights and Labor and our official host was the China Disabled Persons Federation (CDPF). It was a fascinating trip with a full day of formal dialogue, site visits, ceremonial meals, and discussions with some Chinese disability advocates.

CDPF is known in China as a GONGO, a governmental-non-governmental organization, but for all intents and purposes, we were meeting with the Chinese government. The three topics identified for this fourth delegation were rehabilitation, employment of people with disabilities, and adaptive sports. I was invited to represent rehabilitation as one of a seven-member delegation. Other delegates included a senior executive responsible for disability inclusion from Walmart, a disability employment specialist from the Department of Labor, and several State Department officials responsible for the international disability agenda.

The delegation’s official business began as soon as we landed in Beijing after a 14hour flight. We were brought to the U.S. Embassy where we met in the residence of a former senior diplomat. With multiple interpreters in the room, we met with several Chinese disability advocates, including representatives from Handicapped International (“HI”; recently renamed “Humanity and Inclusion”). It was a fascinating dialogue that underscored the differences in disability advocacy in the two countries.

Peter Thomas, JD, tours the Shaanxi Rehabilitation Hospital in Xi’an, China with the hospital administrator and Deputy Assistant Secretary Scott Busby, U.S. Department of State.

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Audacious Goals China is currently pursuing its 13th five-year plan, which began in the 1950s. These plans are grandiose in scope. For instance, under the current five-year plan, China is focusing on improvement of people’s welfare. China intends to eliminate poverty by the year 2020. Its goal, stated many times during the course of the trip, is to

have everyone in China attain “moderate prosperity” by having housing, employment and medical care. They intend to “remodel” the countryside, accelerate the assistive device industry, and create national standards for special education, among other major objectives.

Employment is viewed as a key goal in order to attain moderate prosperity. While most of the cities in China are composed of working-age adults living in one apartment building after another, seniors, children and most people with disabilities tend to live in the rural areas, according to HI. There is a concerted effort to relocate millions of rural Chinese to the cities to be industrious and obtain employment. In fact, one of the cities we visited, Xi’an, a provincial capital city that served as capital of China during 15 different dynasties, is scheduled to grow from a current population of 9 million (the size of New York City) to 15 million people within three years. One can only imagine how long this would take under a democratic government.

To its credit, China has adopted the United Nations Convention on the Rights of People with Disabilities (CRPD)— the U.S. has not yet ratified the CRPD—and appears to be pursuing many policies to come into compliance with that treaty. Article 26 of the treaty addresses the need for member countries to have the capacity to provide comprehensive rehabilitation and habilitation services to the population. China also participated in the development of the World Health Organization’s Rehabilitation 2030: A Call to Action, which establishes a series of goals and benchmarks on rehabilitation access in member countries.

Because of these initiatives, as well as China’s overall interest in showcasing its disability policies as a manifestation of their human rights record, the Chinese government appears eager to make major strides in both rehabilitation and disability policy. Therefore, collaboration with the U.S. rehabilitation and disability communities appears to be a current priority for them.

Dialogue on Rehabilitation The formal day of dialogue started with the President of the CDPF and U.S. Ambassador Terry Branstad offering opening remarks. The rehabilitation discussion followed as the first topic of the day and I presented an overview of rehabilitation in the U.S. Because the Chinese tend to value experience over rhetoric, I peppered my presentation with my own rehabilitation story after bilateral limb loss when I was 10 years old. The fact that I had extensive access to rehabilitation services and prosthetic limbs, remained in a public school (not a segregated one), participated in sports, and eventually became employed as an attorney were all instructive to the main points of the dialogue. I noted that 11 rehabilitation hospitals in China are currently accredited by CARF International, and that standards such as these are critical to ensuring consistency, quality, sustainability and a focus on the person served.

// China has adopted the United Nations Convention on the Rights of People with Disabilities (CRPD) … and appears to be pursuing many policies to come into compliance with that treaty.

China’s presentation was impressive in scope and very focused on numbers. The Director of Rehabilitation for the CDPF related progress China had made under the five-year plan issued in 2017, which identifies rehabilitation as a primary goal. China asserts that 6 percent of the population has disabilities, approximately 85 million people (there are approximately 55 million people with disabilities in the U.S., which has one-third the population of China).

They tend to measure health care in terms of their capacity to deliver services Peter Thomas, JD, meets with Chief Prosthetist of the rather than in outcomes prosthetic/orthotic clinic at Shaanxi Rehabilitation Hospital, Xi’an, China, on April 25, 2018. and results. For instance, China reported it has 450 rehabilitation hospitals, 3,000 rehabilitation units of acute care hospitals, and 75 universities that have rehabilitation as a major.

In fact, China is in the midst of breaking ground on a National Rehabilitation University in southern China that they expect will produce well trained rehabilitation professionals to serve the population in the future.

The CDPF Director of Rehabilitation was candid in assessing China’s continuing challenges in rehabilitation. He admitted that China is lagging behind in sufficient rehabilitation capacity, both buildings and rehabilitation personnel. China provides some rehabilitation following illness or injury but not comprehensive rehabilitation. The sophistication of rehabilitation professionals is fairly low and undifferentiated.

There are still high levels of disability in certain areas of the country, particularly rural areas. Stigma and discrimination continue to be a problem. Many Chinese are aging with chronic conditions. China’s goal is to ensure access to rehabilitation for everyone. In order to accomplish this, five

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immediate goals include the following: Include rehabilitation into the mainstream health care system Improve policies that guarantee access to rehabilitation when needed Increase government subsidies for assistive devices and technologies Focus on children and provide greater public support Mobilize existing rehabilitation capacity and expand private sector investment The CDPF rehabilitation director concluded his remarks with an aspirational statement that China seeks to provide everyday access to rehabilitation. He requested ongoing dialogue and collaboration between the two countries. His remarks were followed by presentations by representatives of rehabilitation programs in China including a spinal cord injury program that appeared very similar to what we would refer to as an independent living center. The day of dialogue continued with an indepth presentation and discussion of employment and sports and recreation for persons with disabilities.

Peter Thomas, JD, presents on U.S. rehabilitation services and devices at the China-U.S. Coordination Meeting on Disability in Beijing, China, on April 24, 2018.

orthotics and prosthetics (O&P) clinic.

There was one room where various prosthetic and orthotic devices and components were displayed on back-lit glass shelves. Some of the household name brands were included in this display but no microprocessors or other advanced technology were included in the exhibit. The gait training area and the fitting room offered a better gauge of the level of quality and sophistication of their O&P capabilities. Of the two patients I met while walking in parallel bars, the prostheses did not appear to fit well, their gate was not optimal, and the prosthetic technology was very basic. A simple strap was being used for suspension rather than more advanced suspension techniques.

The clinic had arranged for a fitting demonstration of a lower limb orthosis and a prosthesis. As the practitioner removed a plaster cast from each patient, I could not help notice the lack of digital scanning technology and other more contemporary fitting equipment.

The hallway featured a display of wheelchairs and fairly basic complex rehabilitative technology (CRT) mobility devices, but I did not see a seating and positioning clinic or a mobility device or O&P laboratory.

Visiting a Rehabilitation Hospital in Xi’an The next morning, the U.S. delegation flew to Xi’an, an ancient city in Shaanxi Province in central China. We toured Potential Future Collaboration Shaanxi Rehabilitation Hospital, an Knowing of multiple past and present aging building in a dense part of interactions between the U.S. the city of Xi’an with multiple floors rehabilitation field and rehabilitation devoted to various rehabilitation hospitals and units in China, there is a services and patient populations. The question as to meaningful next steps. tour itself was fairly chaotic given the The Chinese are clearly focused on extensive number of patients and improving their rehabilitation system Peter Thomas meets Chinese patients at the prosthetic/orthotic family members in the therapy rooms, clinic at Shaanxi Rehabilitation Hospital in Xi’an, China. and are interested in collaborating the entourage accompanying the with the United States as they tour, the many cameras following our pursue this priority. The involvement of the State Department delegation, and the language barrier. I noticed a dearth of as well as the CDPF suggests a more formal collaboration therapy equipment considered standard in the U.S. Where than perhaps previous exchanges between the rehabilitation therapy assist devices and other technology were present, they communities of these two countries on this topic. The most were not always being used. I was not aware of any physician immediate opportunity for collaboration is China’s creation of presence and the therapists were not differentiated in any a National Rehabilitation University, which, while underway, still noticeable way. The physical layout of the building provided appears to be in early stages of development. The inroads the limited room for therapy services to be delivered to the large rehabilitation field has made in China over the past decades patient population, including the pediatric floors. may be ripe for expansion in this environment and new Another portion of the building housed a prosthetic/orthotic clinic. In preparation for this trip, I had asked to tour the

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associations and collaborations appear to be possible.

Identifying Tiering Comorbidities

Garnering comorbidities is one key to capturing the burden of care for inpatient rehabilitation admissions. Comorbidity is defined as a condition other than the impairment or etiologic diagnosis that either existed at the time of admission or developed during the stay, and affects both the treatment received and the length of stay. To determine whether or not the condition should be included as a comorbidity in item 24 of the IRF-PAI, it must pass the active condition test by requiring the following:

Lisa Werner, MBA, MS, SLP

Clinical assessment Additional diagnostic procedures Therapeutic treatment A longer length of stay Enhanced nursing care or monitoring Actively treated comorbidities are reported on the IRF-PAI. Tiering comorbidities will result in additional payment to the rehabilitation hospital or unit. The list of tiering comorbidities was developed to offer reimbursement for the treatment of conditions that increased the cost of the patient’s care and were not considered as or paid for under the patient’s Case Mix Group (CMG).

Comorbidities are derived from the physician’s documentation. Note that the condition must have been present prior to the day before discharge. The CMS IRF-PAI Training Manual advises that conditions diagnosed on either the day of or day before discharge are not considered to add substantially to the resources used to care for the patient, therefore they should not be reported on the IRF-PAI.

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ICD-10 codes for actively treated conditions are usually assigned by the HIM Coder. The ICD-10 codes are entered into the IRF-PAI, assigned a CMG and evaluated by eRehabData®.

If comorbidities are difficult to determine due to inconclusive or non-specific physician documentation, the coder should ask the physician to clarify. Excellent communication between the physician, coder and PPS coordinator is necessary to ensure that coding and completion of the IRF-PAI accurately captures the burden of care.

The following review includes the most common tiering comorbidities and strategies for documentation.

Tier 1 Conditions When a patient has end-stage renal disease that requires dialysis, make sure the dialysis status is captured as a tiering comorbidity. The physician’s notes should state that the patient is on dialysis and the procedure code Z99.2 should be included on the IRF-PAI. When a patient has a tracheostomy tube in place that requires care and management, utilize the code Z43.0 to capture the tiering comorbidity. When the patient has been decannulated but you continue care during the healing process, use code Z93.0.

If a patient presents with dysphagia or a weak, raspy voice, discuss the possibility of vocal cord paralysis or edema of the larynx. These conditions are often associated with cranial nerve injury or vocal cord trauma related to intubation. If the patient was not evaluated for the condition prior to admission, an ENT consult to visualize vocal cord movement may be necessary to complete an accurate diagnosis.

Tier 2 Conditions When a patient has dysphagia, the physician commonly orders a speech-language pathology evaluation. Once a definitive diagnosis is made, make sure the physician indicates the presence and type of dysphagia in the patient’s progress notes.

When the patient is being treated for an infection such as pseudomonas or clostridium difficile, a definitive diagnosis must be made. Make sure the name of the condition is identified in the patient’s progress notes. Resist the potential urge to indicate that the patient is being treated for a possible, probable, or suspected condition.

Tier 3 Conditions The most commonly coded Tier 3 condition is “N17.9 – Acute kidney failure, unspecified.” This condition should be identified when a patient is being treated for an episode of acute kidney failure. Differentiate this from cases of chronic renal insufficiency or acute renal insufficiency.

When a patient has a body mass index of 40 or more, use code “E66.01 – Morbid (severe) obesity due to excess calories.” Make sure the relationship between the patient’s BMI and the obesityrelated condition is documented. Recently, the literature has

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recognized morbid obesity as the patient having a BMI of 35 or more and experiencing one or more obesity-related conditions such as diabetes mellitus, hypertension, or sleep apnea.

Therefore the best practice would be to diagnose the patient with morbid obesity and numerically define their BMI.

// While it is essential for PPS coordinators to maintain strong working relationships with the hospital coders, the coordinators, coders and physicians all must work together to ensure precise coding.

Patients with long-standing diabetes mellitus often present with compromised organs or systems. Make sure to link these manifestations to the cause. For example, you may state neuropathy in diabetes, peripheral vascular disease in diabetes, or diabetic retinopathy. This will ensure more accurate coding and will likely result in a Tier 3 condition. ICD-10 code E11.65 should be used to characterize a patient with uncontrolled diabetes mellitus type 2 who requires sliding scale insulin coverage due to hyperglycemia or hypoglycemia. Typically, I look for peaks or valleys in the blood glucose levels that may indicate the presence of hyper- or hypoglycemia. Notify the physician of such variances so that they may confirm if the complication is indeed present.

Note the different options for tiering comorbidities when a patient presents with heart failure. Heart failure, unspecified (I50.9) is not a tiering comorbidity; however, more specific diagnoses of the same condition are Tier 3 conditions. When labeling the type of congestive heart failure, you should make every attempt to capture a Tier 3 condition. Examples include diastolic heart failure, systolic heart failure, left heart failure, and right heart failure. These conditions may be acute, chronic, or acute on chronic to translate into a Tier 3 ICD-10 code.

It is important to capture the ICD-10 code for treatment of wounds and infections, which usually add to the cost of a patient’s care. In the case of post-operative infections, postprocedure fever, disruption of post-operative wounds, and cellulitis, indicate the source of the infection to translate this into a Tier 3 ICD-10 code.

Several pulmonary conditions like pleural effusion, pneumonia, acute respiratory failure and pulmonary embolism are on the Tier 3 list and are frequently noted in patient assessments.

Make sure that the documentation supports active treatment for these conditions before using them on the IRF-PAI. When the condition is stable and no longer requires treatment, it should not be included as a comorbidity.

In conclusion, ensuring the accurate capture of tiering comorbidities is a responsibility shouldered by coders, physicians and PPS coordinators – who should act as the conduit between the coder and the physician. Further, as the person aware of the final CMG and tier, the PPS coordinator can ask questions about the status of suspected conditions and seek any necessary clarification.

While it is essential for PPS coordinators to maintain strong working relationships with the hospital coders, the coordinators, coders and physicians all must work together to ensure precise coding. Coders must query physicians about incomplete or imprecise documentation. PPS coordinators must have discussions with physicians in order to determine their primary concerns for each patient. Questions that arise from capturing codes can only be clarified through a collaborative approach.

Remember, coders cannot query in a manner perceived as leading, and, as a result, cannot engage in leading discussions with physicians. Therefore, it is imperative that PPS coordinators are involved in coding for IRF-PAI completion to make sure that all questions are answered accurately and in a timely manner. As I have said before, to make sure coding is thoroughly accurate, it really does “take a village.”

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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 / June 2018 13

FY 2019 IRF PPS Proposed Rule Seeks to Use IMPACT Act Function Data for Payment Purposes, Includes Other “Burden Reduction” Proposals

Mimi Zhang, AMPRA Senior Policy and Research Analyst

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

On April 27, the Centers for Medicare and Medicaid Services (CMS) released the federal fiscal year (FY) 2019 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) proposed rule. The rule was published in the May 8, 2018, edition of the Federal Register. Comments are due to CMS on June 26, 2018.

The proposed FY 2019 rules for the acute care hospital prospective payment system (IPPS), long-term care hospitals (LTCH) PPS, and the skilled nursing facilities (SNF) PPS were all issued within the same two weeks. For the FY 2019 proposed changes, CMS estimates the results will be a $75 million increase in IRF PPS payments for FY 2019, which is a net revenue increase of approximately 0.9 percent. The agency also estimates a $42.9 million reduction in costs in FY 2019 due to the proposed changes to coverage and reporting requirements.

Since taking office, President Trump has said he seeks to reduce the number of regulations, reduce government and the burdens imposed by regulations and statutes on businesses and the public. At CMS, these directives have been borne out through the agency’s Patients Over Paperwork initiative, which seeks to evaluate and streamline regulations with a goal to reduce unnecessary burden, increase efficiencies, and to improve the beneficiary experience. In the FY 2018 IRF PPS proposed rule, CMS included a “Request for Information (RFI) on CMS Flexibilities and Efficiencies” inviting ideas for changes with respect to regulatory, sub-regulatory, policy, practice and procedures changes – the whole gamut of how the government issues its policies and practices.

For inpatient rehabilitation hospitals and units (IRH/Us), this desire may translate to reducing many of the Medicare regulations IRH/Us face and that adversely affect patient care and increase costs. In response to that RFI, AMRPA submitted comments with numerous recommendations spanning topics such as the 60

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Percent Rule, the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP), and provider documentation requirements, to name a few.

Several proposals in this year’s proposed rule may be the fruit of CMS’ efforts to reduce the regulatory burden experienced

by IRH/Us, and the field may find some proposals more palatable than others. CMS also continues to carry out its statutory mandates pursuant to the Improving Medicare PostAcute Care Transformation (IMPACT) Act across all post-acute care provider settings. This year’s rule does not propose any additional data collection but instead proposes to remove two measures from the IRF QRP measure set. As always, AMRPA will work closely with its Regulatory and Legislative Policy Committee, Quality Committee, various workgroups, and its membership at-large to analyze the impact of the FY 2019 IRF PPS proposals.

Proposed Removal of the FIMTM Instrument and Revisions to the IRF PPS Case-mix Groups Effective FY 2020 CMS proposes removing the FIMTM instrument and associated Functional Modifiers from the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI) beginning with FY 2020, i.e., effective for discharges beginning on or after October 1, 2019. The FIMTM instrument and associated Function Modifiers are currently used to assign a patient into a case-mix group (CMG) for payment purposes under the IRF PPS. Specifically, CMS proposes to remove the following IRF PAI items: Item 39, which contains 18 of the FIMTM data elements and the FIMTM scale used to assess both motor and cognitive functioning at admission and discharge.

Items 29-38, which contain Function Modifiers associated with the FIMTM instrument.

Pursuant to the IRF QRP, more than 20 data items are collected as Quality Indicators via the IRF PAI on Sections B, C, GG and H. CMS states that because the data elements in the FIMTM instrument “overlap, directly or indirectly,” with data items in the Quality Indicators, the agency can now use Quality Indicators data items for payment purposes, i.e., for assigning patients to CMGs. CMS further states that it is “no longer necessary” to collect FIMTM data and that the continued collection of FIMTM items in addition to reporting the Quality Indicators data places “undue burden” on IRH/ Us. CMS also asserts that transitioning to Quality Indicators items for payment would support its broader goal of using and collecting standardized patient assessment data across postacute care settings. (Several of the Quality Indicators functional data items are also required for skilled nursing facilities [SNFs]).

By the agency’s estimates, removing the FIMTM will generate a $10.2 million reduction in IRH/Us reporting costs in FY 2020.

CMS has published a proposed IRF PAI version 3.0 effective October 1, 2019 (FY 2020). IRF PAI version 3.0, and a table indicating changes from IRF PAI 2.0, are available for download on the CMS IRF PAI website.

Proposed Refinements to the Case-mix Classification System and New Case-mix Groups Effective FY 2020 In order to use Quality Indicator data for payment purposes in place of FIMTM data, CMS proposes to revise to the IRF PPS Case-mix Classification system effective October 1, 2019. Specifically, CMS proposes to use new CMGs, payment weights, and average lengths of stay (ALOS) that are derived from the IRF PAI Quality Indicator data. Consistent with the approach used in the development of the current IRF PPS, CMS and its contractor, RTI International, used Classification and Regression Tree (CART) analysis to create the new CMGs. The analyses used the data collected on the Quality Indicators at patient admission for motor function, cognitive function, and age, during FY 2017 (October 1, 2016 – September 30, 2017).

The proposed rule does not go into great detail regarding the technical analysis used to construct the new CMGs, though CMS issued a technical report accompaniment to the rule, Analyses to Inform the Potential Use of Standardized Patient Assessment Data Elements in the Inpatient Rehabilitation Facility Prospective Payment System. Prepared by RTI International, the report reviews the current use of FIMTM and Quality Indicator data, describes the process used to substitute Quality Indicator data into the IRF PPS, presents the new CMGs and payments weights based on that data, and assess potential impacts to IRH/Us. As readers are well aware, under the current IRF PPS case-mix classification system a patient is assigned into one of 92 CMGs based on the primary reason for rehabilitation care (diagnosis), age and functional status. The functional status component is comprised of a motor score (weighted) and cognitive score (unweighted). However, based on the analysis conducted by RTI International noted above, CMS proposes to revise the case-mix classification system so that the functional status scores is composed of patient’s motor function, a memory function, a communication function (based on comprehension and expression), and age. In other words, the motor score, memory score, communication score and age would feed into the functional status score used to group patients into CMGs under the IRF PPS beginning in FY 2020.

Specifically, CMS proposes to derive various scores from the following Quality Indicator data items: The proposed motor items used to derive the additive motor score are: Eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, bladder continence, bowel continence, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/ bed-to-chair transfer, toilet transfer, walk 10 feet, walk 50 feet with two turns, walk 150 feet, and one step (curb).

These items are collected in Sections GG and H of the IRF PAI. The proposed item used to derive the memory score is the BIMS summary score, which is based on the repetition

AMRPA Magazine / June 2018 15

of three words, temporal orientation, and recall. This is collected in IRF PAI Section C. The proposed communication score is derived from the hearing, speech and vision items collected on IRF PAI Section B. The items assess patients’ expression of ideas and wants and understanding verbal and non-verbal content.

Although the IRF PPS case-mix system currently uses a weighted motor score and an unweighted cognitive score, CMS is not proposing applying a weighting methodology to the motor score at this time. Neither the proposed rule nor the RTI technical report detail why CMS does not propose to use a weighted motor score.

See Table 9 in the rule for the new CMGs, the functional status scores and age that will be used to determine the CMGs, proposed CMG relative weights, and ALOS values effective FY 2020. CMS believes the following would be the most significant technical differences between the current CMGs and the proposed revised CMGs: Four fewer CMGs (88 instead of 92 currently).

Fewer CMGs in RICs 1, 2, 5, 8, 11 and 19.

More CMGs in RICs 3, 4, 10, 13, 15, 17 and 18.

A patient’s age would affect assignment for CMGs in RICs 1, 3, 4 and 13 whereas it currently affects assignment for CMGs in RICs 1, 4 and 8.

Note that CMS is not proposing any changes to the methodology used to update the CMGs, relative weights and ALOS values for FY 2019 (effective for discharges occurring on or after October 1, 2018, and on or before September 30, 2019).

Proposed Updates to the Score Reassignment Methodology Beginning by FY 2020 There are several key differences between the Quality Indicators rating system and the FIM™ rating system: The data items from the Quality Indicators are generally assessed using a six-level rating scale for the self-care and mobility elements and a four-level scale for the cognitive elements. The FIM™ data items use a sevenlevel scale.

The data items from the Quality Indicators are assessed based on a patient’s usual performance during the assessment period, whereas the FIMTM items are assessed based on the patients lowest functional score during the assessment period.

The FIM™ scale includes a value of zero to indicate an activity did not occur or was not observed. In contrast, the Quality Indicator data items use the following four codes to indicate why an activity did not occur: the patient refused to complete an activity (code 07), the patient did not perform this activity (code 09), the activity

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was not attempted due to environmental limitations (code 10), or the activity was not attempted due to a medical condition or safety concern (code 88).

For the self-care and mobility items, CMS proposes to recode values of 07, 09, 10, 88 and the presence of a dash (“-”) to 1, the most dependent level, except the toilet transfer item, which is recoded to 2. CMS also proposes to similarly recode the values for bowel and bladder data items.

Payment Impact Analysis of the New CMGs and Weights CMS proposes to implement the new CMGs in a budgetneutral manner relative to current spending, and hence the distribution of dollars across CMGs will be affected. RTI conducted an impact analysis focused on the percent change in average payments across different provider types and in different geographic areas. It found that on average, across all IRH/Us, the new CMGs would not affect the average payment amount. However, RTI noted several payment redistributions at the provider level: IRH/Us in rural areas would experience a 2.25 percent increase in average payment; Urban IRH/Us would experience a 0.15 percent decrease; Freestanding rehabilitation hospitals would see mean payment decreases (2.43 percent for urban hospitals and 1.37 percent decrease for rural freestanding hospitals); and Rehabilitation units would see mean payment increases (2.77 percent for urban units, and 3.03 percent for rural units).

These estimates assume that a provider’s other payment factors (such as facility-specific adjustors or high-cost outlier payments) would remain unchanged. The estimates also do not account for possible provider behavioral changes. Two tables in the RTI technical report present more granular data on the payment impact by RICs (see Table 11) and by more detailed provider characteristics (see Table 12).

Proposed Changes to Physician Documentation, Supervision Requirements and Use of Non-physician Practitioners Post-Admission Physician Evaluation and Physician Visits In response to suggestions provided to CMS during last year’s rulemaking process, the agency is proposing allowing the Post-Admission Physician Evaluation (PAPE) to count toward one of the required three weekly face-to-face physician visits during the patient’s first week in the IRH/U, beginning FY 2019. CMS states, based on feedback from stakeholders, that it believes that it should be the responsibility of the rehabilitation physician to use his or her best clinical judgment to determine whether the patient needs to be seen more than three times in the first week of admission.

CMS estimates that this will save $40.5 million annually, or an average of approximately $36,000 annually per IRH/U, due to

reduced physician visits. CMS notes however that these cost savings will occur on the Medicare Part B side in the form of reduced Part B payments to physicians. CMS is not proposing to change any other requirements regarding the PAPE, including the requirement it be completed within 24 hours of admission.

Remote Physician Attendance at Interdisciplinary Team Meeting CMS is proposing to amend its regulations to expressly permit the rehabilitation physician leading the required interdisciplinary team meeting to attend the meeting remotely, via either telephone or video conference, beginning in FY 2019. CMS says this change would allow flexibility and convenience for rehabilitation physicians, especially those located in rural areas who may need to travel greater distances between facilities. CMS also makes clear they are proposing for this change to apply only to the rehabilitation physician and not the other required clinicians, but says it may consider expanding this policy to include other team meeting attendees in future rulemaking.

Admission Order Documentation Requirement Beginning FY 2019, CMS is proposing to remove the requirement under regulations specific to IRH/Us at 42 C.F.R. § 412.606(a) that there be a physician order for inpatient care when the patient is admitted to an IRH/U. CMS states it is taking this action because this requirement is duplicative of the requirements under the broader Medicare Part A requirements also applicable to IRH/Us, as well as the Medicare Conditions of Participation (CoPs) regulations, which all require an admission order for all hospital stays.

Remote Face-to-Face Physician Visits CMS is also seeking information on specific areas it can alleviate burden through changes to the requirements pertaining to physician supervision in an IRF. CMS specifically seeks feedback on whether the rehabilitation physician should have the flexibility to determine that some of the three weekly required face-to-face visits can be conducted remotely, such as through video or telephone conferencing. CMS states it would still require at least the majority of physician visits to be face to face, and it has concerns about how remote visits would affect the hospital-level quality of care provided to patients in IRH/Us, but that is also interested in whether this would be an appropriate means by which to lower provider burden. CMS does not expressly state whether it would adopt any changes for FY 2019 or would provide more runway before any changes are implemented.

Use of Non-Physician Practitioners to Meet IRF PPS Coverage Requirements CMS is also seeking information on the use of non-physician practitioners, such as physician assistants and nurse practitioners in IRH/Us. Specifically, CMS wants feedback on whether these clinicians can be utilized to fulfil some of the current IRH/U coverage requirements that are mandated to be completed by a physician. The specific requirements CMS

notes in this section of the proposed rule are the three weekly face-to-face physician visits and the post-admission physician evaluation.

CMS states it would like to explore this possible change, but it has questions about whether non-physician practitioners have the specialized training rehabilitation that would enable them to adequately treat and assess patients, and whether patients will continue to receive the hospital-level and quality of care necessary to treat the complexity of patients found in IRH/Us. As with the use of remote patient visits, CMS does not expressly state whether it would adopt any changes for FY 2019 or would provide more runway before any changes are implemented.

Proposed FY 2019 Payment Updates and Policies CMG Relative Weights As it does every year, CMS proposes to update the CMG weights and ALOS using the most recent available claims and cost report data. Because CMS implements the CMG relative weight revisions in a budget-neutral manner, total estimated aggregate payments to IRH/Us for FY 2019 would not be affected as a result of the proposed CMG relative weight revisions. However, the proposed revisions would affect the distribution of payments within CMGs and tiers.

CMS estimates 99.3 percent of all cases are in CMGs and tiers that would experience less than a five percent change in the CMG relative weight under this proposal, which is the same as last year. CMS says that the CMG with the largest payment increase would the CMG 0806 (Replacement of lower extremity joint, with a motor score less than 22.05 – with no tier adjustment) with a 3.4 percent increase. The biggest decrease would be a 2.1 percent decrease in the CMG relative weight for CMG 0304 (Non-traumatic brain injury, with a motor score less than 26.5 – with no tier adjustment). Table 3 from the proposed rule, replicated below, breaks down the distributional effects of the proposed changes.

CMS provides almost no information on changes to ALOS other than to say after applying the updated data, ALOS changes for FY 2019 are small and do not show any particular trends in IRF length of stay patterns.

Table 3: Distributional effects of the proposed changes to the FY 2019 CMG relative weights (FY 2018 values compared with FY 2019 values) Percentage change in CMG relative weights Increased by 15% or more Increased by between 5% and 15% Changed by less than 5% Decreased by between 5% and 15% Decreased by 15% or more

Number of cases affected 19

Percentage of cases affected 0.0

1,600

0.4

394,149

99.3

1,193

0.3

74

0.0

AMRPA Magazine / June 2018 17

Standard Payment Conversion Factor and Other Adjustments The proposed standard rate conversion factor for FY 2019 is $16,020, an increase factor of 1.35 percent from the FY 2018 standard payment rate conversion factor of $15,838. This increased amount is the result of 2.9 percent rehabilitationspecific market basket update, which is forecasted by a CMS contractor. That update is then reduced by a mandated 0.8 percentage productivity adjustment, a 0.75 percent reduction as required by the Affordable Care Act, and a small budget neutrality adjustment for the CMG relative weights due to the changes described above. Table 5 from the proposed rule, displayed below, provides a breakdown of the proposed increase in the Standard Payment Conversion Factor for FY 2019.

The proposed FY 2019 labor related share of IRH/U payments is 70.6 percent, a slight decrease from 70.7 percent in FY 2018. The decrease is attributable to a 0.1 percent decrease in the subcategory of employee benefits. All other factors contributing to the labor-related share, including wages and salaries and labor-related portions of capital, remain the same as FY 2018.

Table 5: Calculations to determine the proposed FY 2019 Standard Payment Conversion Factor Explanation for adjustment

Calculations

Standard Payment Conversion Factor for FY 2018

$15,838

Market Basket Increase Factor for FY 2019 (2.9 percent), reduced by 0.8 percentage point for the productivity adjustment as required by section 1886(j)(3)(C)(ii)(I) of the Act, and reduced by 0.75 percentage point in accordance with sections 1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(v) of the Act

x 1.0135

Budget Neutrality Factor for the Wage Index and Labor-related Share

x 1.0000

Budget Neutrality Factor for the Revisions to the CMG Relative Weights

x 0.9980

Proposed FY 2019 Standard Payment Conversion Factor

= $16,020

For FY 2019, CMS proposes to apply the same geographic wage areas as used in the FY 2018 IRF PPS final rule for the purposes of wage adjustments. CMS is also proposing to continue to apply a budget neutrality factor as a result of any changes resulting from the updated wage indexes. This year, CMS says that factor will be 1.0, indicating there will be no aggregate change in payments due to the wage indexes. CMS will again continue to hold facility adjustment factors for LowIncome Pool (LIP) payments, rural adjustments and teaching adjustments at the FY 2014 levels. These levels are a LIP factor of .3177; a rural adjustment of 14.9 percent, and a teaching adjustment factor of 1.0163.

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CMS proposes to update the outlier threshold amount from $8,679 to $10,509 for FY 2019 to ensure outlier payments account for 3 percent of total payments, as they did for FY 2018. CMS states at the current threshold, their estimates show that outlier payments would be 3.4 percent of total payments for FY 2019. Due to this change in the outlier threshold, CMS estimates a $35 million decrease in aggregate payments to inpatient rehabilitation providers.

Proposed Policies for the IRF Quality Reporting Program Proposed Removal of Two IRF QRP Measures As part of CMS’ Meaningful Measures initiative, it is proposing to adopt an additional factor to consider when evaluating measures for removal from the IRF QRP measure set – “Factor 8: The costs associated with a measure outweigh the benefit of its continued use in the program.” When a measure’s reporting burden outweighs the evidence supporting its continued use, CMS believes it may be appropriate to remove the measure from the IRF QRP on a case-by-case basis.

Under the guise of Factor 8 above, CMS is proposing to remove two measures from the IRF QRP measure set: National Healthcare Safety Network (NHSN) Facilitywide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716); and Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680).

CMS proposes to remove the MRSA measure from the IRF QRP measure set beginning with the FY 2020 IRF QRP, and to remove the patient influenza vaccine beginning with the FY 2021 IRF QRP. If finalized as proposed, IRH/Us would no longer be required to submit data on these measures for the purposes of the IRF QRP beginning with October 1, 2018, admissions and discharges. Since the patient influenza measure is reported on the IRF PAI, CMS is proposing that providers enter a dash (-) for items O0250A, O0250B and O0250C on the IRF PAI version 2.0 (effective October 1, 2018) until IRF PAI version 3.0 is released.

Rationale In examining its data, CMS found that the number of IRH/Us with expected MRSA infections is extraordinarily low. For 99.9 percent of providers, the expected MRSA infection incident rate is less than one, which is too low for CMS to be able to calculate reliable and publicly reportable measure rates. Accordingly, CMS finds the costs and burden associated with this measure, which include the costs to maintain and publicly report it for the IRF QRP and its relevancy for only for a few facilities, outweigh the benefit of its continued use in the program. AMRPA has previously recommended that CMS remove this measures for these reasons and is pleased to see the agency’s proposal.

Similarly, CMS has found that provider performance on the patient influenza vaccine measure has “topped out,”

meaning that performance among all IRH/Us is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made. CMS reports that IRH/ Us’ mean performance scores for the 2015-2016 influenza season was 91.04 percent, and 93.88 percent for the 2016-2017 performance year. This suggests a potential ceiling effect and a lack of variation that restricts distinction between providers.

Proposed Public Display of Functional Measure Data on IRF Compare CMS proposes to begin publicly displaying data on the four functional outcomes measures in CY 2020, or as soon thereafter as technically feasible. The measures are: Change in Self-care (NQF #2633); Change in Mobility Score (NQF #2634); Discharge Self-care Score (NQF #2635); and Discharge Mobility Score (NQF #2636).

The publicly displayed data will be based on four rolling quarters of data, initially using discharges from January 1, 2019, through December 31, 2019. CMS proposes that providers with fewer than 20 cases during any of the four consecutive rolling quarters will not have their data displayed in order ensure statistical reliability. Inpatient rehabilitation providers began reporting these measure on the IRF PAI on October 1, 2016.

Proposed Changes to Reconsideration Requirements under the IRF QRP Currently, providers found to be noncompliant with the IRF QRP reporting requirements for a given fiscal year will receive a letter notifying them of their noncompliance through the Quality Improvement and Evaluation System Assessment Submission and Processes (QIES-ASAP) system and through the U.S. Postal Service (USPS). CMS is proposing to expand its notification methods to state that it would notify providers of noncompliance via a letter sent through at least one of the following notification methods: the QIES-ASAP system, USPS or via an email from the provider’s Medicare Administrative Contractor (MAC).

CMS also proposes to notify providers in writing of its final decision regarding any reconsideration request using the same notification process.

Delaying Implementation of the Transfer of Health Information Measures In the FY 2018 IRF PPS final rule, CMS stated its intention to propose two measures that would satisfy the domain of “accurately communicating the existence and provision of the transfer of health information and care preferences” no later than October 1, 2018. This domain, transfer of health information, is required by the IMPACT Act. In last year’s rule, CMS had intended to propose them for data collection beginning on or about October 1, 2019.

In this proposed rule, CMS states that this timeline is now delayed and the agency intends to specify transfer of health measures no later than October 1, 2019. CMS expects to propose the measures be collected beginning on or after

// CMS issued draft specifications for public comment for two measures that assess the transfer of a medication profile information after patient discharge. The AMRPA Quality Committee reviewed the measures and provided written comments to CMS with recommendations to pare down the measures’ scope of data collection.

October 1, 2020, and reporting compliance would apply to the FY 2022 IRF QRP. This spring, CMS issued draft specifications for public comment for two measures that assess the transfer of a medication profile information after patient discharge. The AMRPA Quality Committee reviewed the measures and provided written comments to CMS with recommendations to pare down the measures’ scope of data collection.

Accounting for Social Risk Factors Social risk factors, such as beneficiaries’ income levels, educational attainment or dual-eligible status, can be associated with poor health outcomes and some of this disparity is related to the quality of health care. Hospital stakeholder groups have encouraged CMS to account for social risk factors in the agency’s quality reporting programs so that there can be a more equitable assessment of provider outcomes and quality performance.

CMS is not proposing to account for social risk factors in the IRF QRP at this time, stating that it continues to consider options to reduce health disparities and increase transparency about disparities in its quality programs.

However, in the FY 2019 Inpatient Prospective Payment System (IPPS) proposed rule, CMS proposes to begin accounting for social risk factor in the Hospital Value-based Purchasing (VBP) Program for general acute care hospitals by including performance rates for certain measures stratified by patients’ dual eligibility status. The success of this approach, which is proposed to begin in fall 2018, may have bearing on whether it is also incorporated into post-acute care providers’ QRPs in future years.

AMRPA Magazine / June 2018 19

Request for Information on Promoting Interoperability and Electronic Health Care Information Exchange In light of increasingly high percentage of providers adopting the use of certified electronic health records (EHR), CMS is seeking comments from stakeholders on how it could amend the Medicare CoPs, Conditions for Coverage (CfCs), or Requirements for Participation (RfPs) that facilities must adhere to in order to make the exchange of certain health information about patients mandatory. Some specific ideas that CMS requests feedback on in this Request for Information (RFI) includes amending the CMS CoPs to require that hospitals electronically transfer medically necessary information to another facility or provider upon a patient transfer or discharge, and also require that hospitals make certain information available to patients or third-party applications via electronic means if requested.

CMS also references a discharge planning proposed rule issued in 2015 that addressed several elements of provider

communications at patient transitions. The discharge planning rule proposed that in accordance with the IMPACT Act, hospitals, critical access hospitals, and certain post-acute care providers would be required to inform patients of downstream providers’ performance on quality and resource use measures as part of the discharge planning process.

Beyond exchange of information between providers, CMS is also seeking information on enhancing access to health records for patients. CMS raises its new MyHealthEData initiative and Blue Button 2.0 project, which aim to provide more usable access to health records for patients. CMS says that many beneficiaries currently have access to their records, but without any context or other information that would help them digest the materials, that access is largely useless. CMS requests information on ideas to help break down any barriers that stakeholders have identified that are preventing patients from having meaningful access to their own health data.

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

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CMS Releases IPPS and LTCH Proposed Rule for 2019; Lifts Restrictions on Excluded Units

The Centers for Medicare and Medicaid Services (CMS) published the fiscal year (FY) 2019 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Longterm Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule in the Federal Register on May 7, 2018. In this rule, CMS is taking a number of steps to attempt to reduce provider burden, as well as proposing to lift restrictions on satellite facilities and IPPS-excluded units of hospitals which may impact inpatient rehabilitation hospitals and units’ (IRH/U) operations.

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

Highlights: »»

Proposal would permit IPPS excluded-hospitals to operate units

»»

Quality reporting programs to see reduction in reported measures

Satellite Facilities Last year, CMS altered its regulations so that two co-located hospitals (referred to as a hospital within a hospital [HwH]) no longer had to comply with separateness and control requirements for these arrangements when both of those hospitals were IPPS-excluded hospitals (i.e., an IRH and an LTCH). The separateness and control requirements continue to apply when an HwH involves a general, acute care IPPS hospital. However, there are similar separateness and control requirements when a facility is a satellite facility. Similar to the changes to HwH requirements, CMS is now proposing to remove the separateness and control requirements for satellite IPPS-excluded hospitals that are co-located with other IPPS-excluded hospitals. Therefore, a satellite would only need to continue to comply with these separateness and control requirements should it be co-located with an IPPS hospital. Additionally, CMS is proposing to revise the regulation so that an IPPSexcluded satellite facility of an IPPS-excluded unit of an IPPS-excluded hospital would not have to comply with the separateness and control requirements so long as the satellite of the excluded unit is not co-located with an IPPS hospital.

IPPS-Excluded Units In this year’s rule, CMS also proposes to change its regulations so that an IPPSexcluded unit can be part of an IPPS-excluded hospital, so long as the unit is not of the same type as the hospital. Current regulations dictate than an IPPS-excluded unit (IRU or psychiatric unit) can only be a unit of an IPPS hospital, and not part of an IPPS-excluded hospital. This change would mean an LTCH could operate IRU and/or

22 AMRPA Magazine / June 2018

psychiatric units, or an IRH could operate psychiatric units, but IRHSs and psychiatric hospitals could not operate LTCH units, since current regulations do not permit LTCH units. CMS also makes clear in this proposal that nothing under the Medicare Conditions of Participation (CoPs) would change, so that the units would need to remain fully compliant with all CoPs applicable to the rest of the hospital and vice versa.

IPPS Payment Changes As it does every year, CMS updates the payment rates and adjustments for IPPS hospitals. The proposed increase in rates for general acute care hospitals paid under the IPPS this year is 1.75 percent. This increase is the result of a 2.8 percent increase in the market-basket, reduced by a 0.8 percentage point productivity adjustment. The 1.75 percent also reflects a proposed -0.25 percentage point adjustment required by recent legislation.

CMS also proposes an increase in the distribution of disproportionate share hospital (DSH) funds by $1.5 billion dollars compared to last year, bringing the total to $8.25 billion in uncompensated care payments for FY 2019. CMS projects that these changes, along with proposed changes to IPPS payment policies, will increase IPPS by approximately 3.4 percent overall in FY 2019. After also factoring in potential reductions due to value-based pe nalties and other programs, CMS projects that total Medicare spending on inpatient hospital services will increase by about $4 billion in FY 2019.

CMS is also proposing, as required by statute, that the current post-acute care transfer payment policy will now apply to transfers to hospice care. In order for a hospice transfer claim to be subject to this payment policy, the patient needs fall into an MS-DRGs that is currently subject to this policy for transfers to other post-acute care sites.

EHR Incentive Programs In this rule CMS is conducting what it refers to as an overhaul of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs to refocus the program on interoperability and lessen provider burden. As a part of this, CMS is proposing to rename the program “Promoting Interoperability.” Further, CMS is proposing a new scoring methodology and new measures that align with agency priorities aiming to address opioid and substance use disorders. A number of measures are also being removed based on CMS assessment that they do not adequately prioritize interoperability and the electronic exchange of health information. On top of these changes, CMS also released an Request for Information (RFI), which is identical to the one found in the FY 2019 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) proposed rule. This RFI seeks feedback on potential changes to the Medicare CoPs and other regulations to require the electronic exchange of health information as a condition of participation or of coverage.

Public Price Transparency In this proposed rule, CMS is updating its requirements that hospitals make available a list of their standard prices. This

update would require hospitals to make available its standard prices via the Internet and in a machine readable format.

The agency also issued an RFI on price transparency, and it seeks feedback from stakeholders on how to further improve consumers’ understanding of out-of-pocket costs. CMS also requests information from providers on how CMS should penalize providers for non-compliance, as well as how Medigap plans contribute to consumers’ grasp of health care costs.

// CMS proposes to remove 18 previously adopted measures that are topped out, no longer relevant or where CMS has decided the burden of data collection outweighs its value.

Quality Reporting and Value-based Purchasing CMS is proposing to refine the measures required to be reported under the Hospital Inpatient Quality Reporting Program (IQR). CMS proposes to remove 18 previously adopted measures that are topped out, no longer relevant or where CMS has decided the burden of data collection outweighs its value. CMS is also proposing to de-duplicate 21 measures by removing those that also appear in one of the four other IPPS hospital quality programs. CMS is seeking comment on two potential new quality measures for future inclusion in the IQR and also states it will begin accounting for social risk factors in the IQR by including measure rates stratified by patients’ dual eligibility status for Medicare and Medicaid. For the Hospital Value-based Purchasing (VBP) Program, CMS is also proposing to remove 10 measures that are duplicated in one of the other quality reporting programs. CMS is also proposing to reweight the performance scores under the Hospital VBP Program to give more weight to the clinical care domain score.

Burden Reduction The agency also made a number of additional proposals in an effort to reduce provider burden and increase provider efficiency. First, CMS is proposing removing the requirement that admission certification statements, when required, detail where in the medical record the supporting information for the certification can be found. In addition, CMS is proposing removing the regulatory mandate that an admission order be present in the medical record as a specific condition of Medicare Part A payment. Finally, the agency is also proposing allowing new urban teaching hospitals to enter into Medicare Graduate Medical Education (GME) affiliation agreements, which allow hospitals to share full‑time equivalent cap slots to permit the hospitals to share the training responsibilities.

AMRPA Magazine / June 2018 23

LTCH Payment Changes In addition to updates to the IPPS, CMS also proposes updates to the LTCH PPS in this rule. CMS is proposing a 1.15 percent increase in payments under the standard LTCH payment rates.

This increase is the result of a market basket increase of 2.7 percent, less a 0.8 percentage point productivity adjustment and a 0.75 percentage point statutorily required reduction. In addition, CMS is making a statutorily required change to those payments made under the site-neutral payment system for LTCHs, which is a blend of the LTCH PPS and IPPS-equivalent rates. Cases that qualify to be paid under the site-neutral policy will be reduced by 4.6 percent from the current fiscal year until at least 2026. CMS estimates that aggregate FY 2019 LTCH PPS payments will be approximately $4.510 billion, as compared to $4.515 billion in FY 2018, resulting in an estimated overall decrease in LTCH PPS payments of approximately $5 million.

25-percent Rule The 25-percent threshold policy, also referred to as the 25-percent rule, restricts LTCHs from admitting any more than 25 percent of their patients from any one referring source, such as a single acute-care facility. Any claims for patients discharged above the 25-percent threshold may have their payment adjusted to the IPPS equivalent payment amount for that claim. This provision has been subjected to multiple statutory and regulatory moratoriums over the last several years. This year, CMS is proposing to permanently remove the 25-percent rule. CMS also states that due to the removal of

24 AMRPA Magazine / June 2018

the 25-percent rule, it anticipates a net increase of $36 million in aggregate payments to LTCHs. As a result, it is proposing to apply a budget neutrality factor of 0.9905 to the LTCH prospective payment rates for FY 2019.

LTCH QRP Similar to its proposals in the IPPS and IRH/U proposed rules, CMS is proposing removing measures from the LTCH QRP that it finds overly burdensome or duplicative of other programs’ requirements. Those measures proposed for removal are the National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716) (beginning with the FY 2020 LTCH QRP), NHSN Ventilatorassociated Event (VAE) Outcome Measure (beginning with the FY 2020 LTCH QRP) and Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (NQF #0680) (beginning with the FY 2021 LTCH QRP). LTCHs that do not submit the required measures under the LTCH QRP are penalized with a 2 percent reduction.

However, CMS is also proposing to alter the way in which it notifies hospitals of QRP noncompliance so that a hospital may now be notified of noncompliance via certified mail or electronic mail.

AMRPA’s relevant committees will be evaluating this rule and submitting formal responses to CMS, as is deemed necessary.

The final rule will be expected in late summer.

FY 2019 SNF PPS Rule Proposes Major Change to Nursing Home Payment System

The Centers for Medicare and Medicaid Services (CMS) issued the federal fiscal year (FY) 2019 proposed rule updating Medicare payment policies and rates under the Skilled Nursing Facility Prospective Payment System (SNF PPS), the SNF Quality Reporting Program (SNF QRP), and the SNF Value-Based Purchasing (SNF VBP) Program in the May 8, 2018, edition of the Federal Register. This article covers several key provisions in the proposed rule.

Mimi Zhang, AMRPA Senior Policy and Research Analyst

Highlights: »»

Aggregate payments to skilled nursing facilities proposed to increase by $850 million in FY 2019

»»

CMS proposes replacing the RUG-IV payment system with a new system called the Patient Driven Payment Model in FY 2020

Changes to SNF PPS Payment Rates Based on proposed changes contained within this proposed rule, CMS estimates that the FY 2019 aggregate impact will be an increase of $850 million in Medicare payments to SNFs, due to the Bipartisan Budget Act of 2018, which requires the FY 2019 SNF market basket update required to be 2.4. Without this statutory requirement, the FY 2019 market basket update factor would have been 1.9 percent, which reflects the SNF FY 2019 market basket index of 2.7 percent, reduced by the multifactor productivity adjustment of 0.8 percent. CMS estimates that the 1.9 percent update would have resulted in an estimated aggregate increase of $670 million in Medicare payments to SNFs. Modernizing the SNF PPS Case-mix Classification System Last year, CMS released an Advanced Notice of Proposed Rulemaking (ANPRM) outlining a new case-mix model, called the Resident Classification System, Version I (RCS-I). CMS considered replacing the Resource Utilization Group, Version IV (RUG-IV) case-mix model currently used to classify residents into payment groups under the SNF PPS. Due to stakeholder feedback to the ANPRM however, CMS continued to reshape the RCS-I in efforts to address the concerns and questions raised by commenters. Accordingly, it made significant revisions to the RCS-I model and in this rule unveils a new model referred to as the SNF Patient-Driven Payment Model (PDPM). CMS proposes that the PDPM would be effective October 1, 2019 (FY 2020).

AMRPA Magazine / June 2018 25

// The new PDPM model is designed to reduce Medicare spending and improve care by tying payment to resident conditions rather than the minutes of therapy provided.

The new PDPM model is designed to reduce Medicare spending and improve care by tying payment to resident conditions rather than the minutes of therapy provided. Under the PDPM, Medicare payment would be based on five casemix adjusted components: Physical therapy (PT) Occupational therapy (OT) Speech-language pathology (SLP) Nursing, which covers utilization of nursing services and social services Non-therapy ancillary (NTA) services (items and services not related to the provision of therapy such as drugs and medical supplies).

Payment would be calculated by multiplying the case-mix index for the resident's group with each component, first by a base payment rate and then by days of service received.

The payment calculations for each component would then be added together to create a resident's total per diem rate. For the PT, OT and NTA components, the PDPM includes variable per-diem payment adjustments that modify payment based on changes in utilization of these services over the course of a stay. PDPM, as compared to RCS-I, would also utilize of certain standardized items for payment calculations, such as in using function items being collected in the SNF quality reporting program (SNF QRP).

CMS states that the proposed PDPM reflects an approximately 80 percent reduction in the number of payment group combinations compared to the RCS-I. Additionally, it reflects updates to the data used as the basis for CMS’ analyses, to ensure that the results reflect the current resident population. CMS believes the PDPM would move Medicare towards a more value-based, unified post-acute care payment system while also reducing facilities’ administration burden.

26 AMRPA Magazine / June 2018

CMS also proposes to include additional therapy reporting requirements to the MDS focused on documenting a resident’s therapy minutes and therapy modes, and the days for each discipline and mode of therapy. Since the inception of the SNF PPS, CMS has limited the amount of group therapy to each Part A resident to 25 percent of the therapy provided to them by discipline. In this rule, CMS proposes to limit both group and concurrent therapy to no more than 25 percent of a resident’s therapy minutes by discipline. With the new therapy documentation requirements, CMS seeks to add a mechanism by which it can monitor SNFs’ compliance with group and concurrent therapy limits.

SNF Quality Reporting Program (QRP) As seen in several Medicare payment rules this year, CMS proposes to adopt an additional factor to consider when evaluating measures for removal from the SNF QRP measure set. This factor would take into account costs that are associated with a measure and weighs them against the benefit of its continued use in the program. CMS is also proposing to publicly display data for the self-care and mobility SNF QRP measures in CY 2020. The measures are: Change in Self-care Score (NQF #2633) Change in Mobility Score (NQF #2634) Discharge Self-care Score (NQF #2635) Discharge Mobility Score (NQF #2636) SNFs are required to submit data on these four assessmentbased measures beginning October 1, 2018. CMS also proposes to increase the number of years of data used to publicly display two claims-based SNF QRP measures, Discharge to the Community and Medicare Spending per Beneficiary, from one year to two years. CMS does not propose to adopt any new measures for the SNF QRP in this rule.

SNF Value-Based Purchasing Program (VBP) Beginning October 1, 2018, the SNF VBP Program will apply either positive or negative incentive facilities’ payment based on their performance on the program’s readmissions measure. Performance is based on the claims-based all-cause 30-day hospital readmissions measure. This single measure does not require SNFs to report information in addition to the information they already submit as part of their claims because CMS uses existing Medicare claims information to calculate the measure. While CMS would update policies such as program baseline periods, it is not proposing major changes to the SNF VBP in this rule.

Comments on the proposed rule are due to CMS by June 26, 2018.

MedPAC Develops Uniform PAC Outcomes Measures, Turns Attention to PAC Value-based Purchasing

On April 5-6, 2018, the Medicare Payment Advisory Commission (MedPAC) held public meetings that included the session, Uniform Outcome Measures for Post-Acute Care. In this session, MedPAC staff presented a “proof of concept” for the following three claims-based post-acute care (PAC) outcomes measures and sought the commissioners’ feedback on further development work:

Mimi Zhang, AMRPA Senior Policy and Research Analyst

Highlights: »»

MedPAC presents outcomes data on readmissions and Medicare Spending per Beneficiary measures for IRH/Us, SNFs and HHAs.

»»

The measures could be used in a post-acute care value based purchasing program.

Readmissions during the PAC stay: Potentially preventable and all-cause Readmissions 30-days post-discharge: Potentially preventable and all-cause Medicare Spending Per Beneficiary (MSPB): PAC stay plus 30 days postdischarge These measures, though similar to ones currently used by the Centers for Medicare and Medicaid Services (CMS) in PAC quality reporting programs, were developed independently by MedPAC and are technically different from CMS’ measures. Of note, MedPAC intends to develop a PAC value-based purchasing (PAC VBP) program in the coming year, and a provider’s outcome on uniform measures could be used as the basis for a PAC VBP score. MedPAC states that the VBP program could be implemented either under current setting-specific payment systems or under a unified PAC payment system.

Readmissions Measures Working with its contractor Providigm, MedPAC has developed risk-adjusted readmissions measures for inpatient rehabilitation hospitals and units (IRH/Us), home health agencies (HHAs), and skilled nursing facilities (SNFs). MedPAC excluded long-term care hospitals (LTCHs) because some readmissions from LTCHs to acute care hospitals are not reported due to the interrupted stay policy and because the patient assessment data used to risk adjust the measures was not collected by LTCHs when MedPAC conducted this analysis. Observed rates were risk adjusted using patient characteristics such as age, gender,

AMRPA Magazine / June 2018 27

comorbidities, functional status and cognitive status.

Hospital admissions from the community were excluded.

MedPAC staff state that its readmissions measures use identical definitions for “within-stay” and a risk-adjustment model that is more aligned across settings, and are therefore more comparable across settings than those measures currently implemented by CMS in quality reporting programs.

// The better performing/ low-MSPB providers were “disproportionately” nonprofit and hospitalbased, according to the staff.

Table 1: MedPAC data on provider-level risk-adjusted rates of readmission, 2014 Measure

IRH/U

SNF

HHA

All

During stay Potentially avoidable All-cause

4.1%

11.3%

15.9%

12.4%

12.0%

23.9%

33.8%

26.4%

During 30 days after discharge Potentially avoidable All-cause

5.1%

6.1%

5.2%

5.7%

12.5%

13.2%

12.0%

12.8%

MedPAC’s analysis found post-discharge readmission rates to be similar across settings, with SNFs having the highest post-discharge readmission rates (see table 1). Within-stay readmission rates varied considerably by PAC setting for both the potentially avoidable and all-cause readmission measures. On average, HHAs had the highest within-stay readmission rates and IRH/Us had the lowest. MedPAC staff attributed these variations to two factors, stating that: Settings differ in their infrastructure and that affects their readmission rates. IRH/Us, as licensed hospitals with physician staffing presence, are more likely to detect and manage conditions that elsewhere could develop into a hospitalization.

Medicare Spending Per Beneficiary The design of MedPAC’s PAC-MSPB measure is similar to what is currently implemented in CMS’ quality reporting programs although MedPAC uses a different risk-adjustment methodology than CMS. Each PAC stay triggers an MSPB episode which concludes 30 days after patient discharge from the triggering PAC provider. For example, a stroke patient who has a 15-day IRH/U stay and is then discharged to home health would trigger an IRH/U MSPB episode and a HHA MSPB episode. The IRH/U’s MSPB measure would include the entire IRH/U stay and the first 30 days of the HHA stay.

The MSPB measure includes total Parts A and B spending and is standardized for geographic wage differences and facility add-on payments. Provider performance is calculated by comparing a provider’s average spending to that of its setting and is not assessed across settings.

MedPAC staff outlined the following MSPB results, stating that a “low MSPB is considered desirable:”

Stays vary considerably by length and by setting, so the risk of readmission will vary as a function of how long the beneficiary was in the setting. For example, SNF stays are about twice as long as IRH/U stays.

MedPAC also analyzed provider performance across PAC settings by segmenting all providers into performance quintiles. They found considerable variation among the quintiles.

For the within-stay measures: Potentially avoidable readmissions: Readmission rates for the 90th percentile of providers were almost four times higher than for the 10th percentile.

All-cause readmissions: There was a three-fold variation between the 90th and 10th percentiles.

Post-discharge readmissions were more variable: Potentially avoidable: Rates at the 90th percentile were almost six times as those at the 10th percentile.

All-cause: Rates at the 90th percentile were almost three times that for the 10th percentile.

28 AMRPA Magazine / June 2018

There was more variation among SNFs than any other setting, with a 1.8-fold difference between top and low performers.

Providers with better performance (the quartile with lowest MSPB spending) had an average spending that was 20 percent lower than the quintile with high MSPB spending.

MedPAC also broke down total costs by Initial PAC, Other PAC, Hospital, Fee schedule, Ancillary and other.

The biggest driver for the variation was Other PAC spending: Low-MSPB PAC providers spent 34 percent less on Other PAC than high-MSPB providers.

The better performing/low-MSPB providers were “disproportionately” nonprofit and hospital-based, according to the staff.

Opportunities for MSPB improvement would vary considerably by market.

Finally, MedPAC staff discussed the tradeoff between a quality measure’s reliability/accuracy and its minimal volume count and suggested several approaches to address this issue for small providers, such as pooling data over multiple years or across providers, e.g., those in a health care system, company or market. Over the coming year, MedPAC plans to explore other uniform PAC outcomes measures, which may include: Discharge to community.

Combined measure of potentially preventable admissions and readmissions. This would include community-based admissions.

Commissioner Feedback and Next Steps In the discussion period that followed, MedPAC commissioners supported continuing to develop uniform PAC outcomes measures in the coming year, and several expressed their appreciation of cross-setting PAC comparative outcomes data. Several commissioners also advised the staff to evaluate whether functional data being collected in several PAC settings could be used to develop functional outcomes measures MedPAC’s next public meeting will take place September 7-8, 2018. In June, MedPAC will release its June Report to Congress, which is expected to include a chapter on issues in refining the uniform PAC PPS, specifically on payment adjusters for sequential PAC stays.

More information on public meetings, including presentation slides and a transcript, can be found at http://medpac.gov/-public-meetings-.

Number of days between leaving home and returning after a hospitalization and/or PAC. Patient experience measure and exploring an instrument to be used by PAC patients.

AMRPA Magazine / June 2018 29

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Regulatory, Legislative, and Accreditation Matters Outside the Box

Coalition to Preserve Rehabilitation Urges CMS to Increase Its Oversight of Prior Authorization Under the Medicare Advantage Program April 9, 2018 VIA ELECTRONIC MAIL Seema Verma Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244 On April 9, 2018, members of the Coalition to Preserve Rehabilitation (CPR) submitted comments to the Centers for Medicare and Medicaid Services (CMS) regarding increasing its oversight of the use of prior authorization and proprietary coverage guidelines by Medicare Advantage (MA) plans to ensure that beneficiaries in MA plans have adequate access to rehabilitation services. This letter was provided.

Re: E xtensive Use of Prior Authorization in Medicare Advantage Plans Restricts Access to Medical Rehabilitation for Medicare Beneficiaries Dear Administrator Verma: The undersigned members of the Coalition to Preserve Rehabilitation (“CPR�) write to ask the Centers for Medicare and Medicaid Services (CMS) to eliminate the administrative barriers to patient access to medically necessary rehabilitation services and devices that are often imposed through the use of prior authorization in Medicare Advantage (MA) plans. CPR is greatly concerned that prior authorization requirements in MA plans may be sources of increasing barriers to accessing needed care, particularly inpatient and outpatient rehabilitation services and devices, for beneficiaries nationwide.

CPR is a coalition of national consumer, clinician, and membership organizations that advocate for policies to ensure access to rehabilitative care so that individuals with injuries, illnesses, disabilities and chronic conditions may regain and/or maintain their maximum level of health and independent function. CPR is comprised of organizations that represent beneficiaries who are frequently inappropriately denied access to rehabilitative care in a variety of settings, as well as the providers who serve them.

Medicare Advantage served almost 19 million Medicare beneficiaries in 2017 comprising 32 percent of the total Medicare population, according to MedPAC. MA plans were paid approximately $210 billion in this same year. By 2028, MedPAC estimates that 32 million beneficiaries will participate in the MA program. The fast pace of growth of this program suggests the need for greater scrutiny of mechanisms imposed by these plans to manage service utilization, such as prior authorization.

While prior authorization requirements may be appropriate in some limited circumstances to ensure that patients are receiving medically necessary care, the use of such requirements has become increasingly routine in MA plans. Often, the use of prior authorization in these circumstances is difficult to justify. Many plans utilize prior authorization processes for items and services that are routinely approved.

Additionally, the use of prior authorization to approve care including rehabilitation services and devices, transplantation, non-elective surgeries, and cancer care is especially hard to justify, given that these and many similar medical services are unlikely to be over-utilized and often need to be provided in a timely manner in order to maximize their medical efficacy.

AMRPA Magazine / June 2018 31

In these cases and others, prior authorization often serves as an unnecessary delay for beneficiaries seeking medically necessary care, and often results in no cost savings to the plan. CPR is especially troubled to have learned of reports of some managed care plans’ use of benefits management companies that are incentivized based on the number or dollar amount of services they deny.

Federal law states that MA beneficiaries are entitled to the same benefits available under Medicare fee-for-service (FFS).

(See id. § 422.100(f)(1)-(3).) Medicare regulations also stipulate that MA Plans must comply with FFS coverage guidelines and national and local coverage determinations subject to limited exceptions for coverage uniformity across geographic areas.

(See, 42 C.F.R. § 422.101(b)(2). Rather than abiding by Medicare coverage criteria, MA plans typically impose prior authorization and utilize proprietary admission or coverage guidelines, such as those marketed by Milliman and Interqual, to justify a denial of rehabilitation coverage.

These guidelines often contradict well-established best practices in medicine, such as the American Heart Association and American Stroke Association’s (AHA/ASA) guidelines for stroke recovery. AHA/ASA “strongly recommends that stroke patients be treated at an in-patient rehabilitation facility rather than a skilled nursing facility.” In fact, the Medicare Payment Advisory Commission found that 2015 MA admissions to inpatient rehabilitation hospitals were one third of admissions to this same setting under Medicare fee-for-service. (See, MEDPAC, REPORT TO THE CONGRESS: MEDICARE PAYMENT POLICY, P. 298 (Mar. 2017).

Recently, private insurers have begun focusing on ways to limit the negative impact of prior authorization on access to medically necessary care while ensuring beneficiaries do not receive medically unnecessary services. CPR urges CMS to consider implementing similar policies in MA plans as well, to ensure that prior authorization processes do not prevent beneficiaries who elect to participate in MA plans from accessing needed care, especially rehabilitation services and devices in both the inpatient and outpatient settings.

To do so, CPR recommends that CMS increase oversight of the use of prior authorization in MA plans. Such oversight should include stronger directives to MA plans to limit the use of prior authorization to services that are demonstrably over-utilized.

CMS should also review the list of services that each MA plan subjects to prior authorization, prohibit the use of proprietary coverage guidelines as a substitute for fee-for-service coverage criteria, and ensure that MA beneficiaries are provided with comprehensive information disclosing the use of prior authorization in their plan.

32 AMRPA Magazine / June 2018

CPR appreciates the opportunity to comment on the use of prior authorization in MA plans. For more information, please contact Peter Thomas, coordinator for CPR by e-mailing Peter.Thomas@ PowersLaw.com or by calling 202-466-6550.

Sincerely, Academy of Spinal Cord Injury Professionals (ASCIP) ACCSES American Association of People with Disabilities (AAPD) American Academy of Physical Medicine and Rehabilitation (AAPM&R) American Association on Health and Disability (AAHD) American Congress of Rehabilitation Medicine (ACRM) American Medical Rehabilitation Providers Association (AMRPA) American Occupational Therapy Association (AOTA) American Physical Therapy Association (APTA) American Spinal Injury Association (ASIA) American Therapeutic Recreation Association (ATRA) Amputee Coalition The Arc Association of Academic Physiatrists (AAP) Association of University Centers on Disabilities (AUCD) Brain Injury Association of America (BIAA) Center for Medicare Advocacy Christopher & Dana Reeve Foundation Clinician Task Force (CTF) Disability Rights Education and Defense Fund (DREDF) Epilepsy Foundation Falling Forward Foundation Lakeshore Foundation The Michael J. Fox Foundation for Parkinson’s Research National Association for the Advancement of Orthotics and Prosthetics (NAAOP) National Multiple Sclerosis Society (NMSS) National Association of State Head Injury Administrators Paralyzed Veterans of America (PVA) United Spinal Association

Cc: Demetrios Kouzoukas, Principal Deputy Administrator for Medicare, CMS Cathy Baldwin, Director, Division of Medicare Advantage Operations

New Interim Final Rule to Provide Relief for Providers Through Increased Fee Schedule Rates Through 2018

The Centers for Medicare and Medicaid Services (CMS) issued an interim final rule with comment period (IFC) to increase the fee schedule rates from June 1, 2018, through December 31, 2018, for certain durable medical equipment (DME) items and services. Stakeholders have raised concerns about significant financial challenges the current adjusted DME fee schedule rates pose for suppliers, including many small businesses, and that the number of suppliers in certain areas continues to decline.

In 2016 and 2017, information from the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) was used to adjust Medicare payments for certain DME and enteral nutrition in certain areas of the county where the CBP did not occur (“non-bid areas�). The CBP has not been implemented in rural areas comprising about half the volume of the volume of items and services furnished in non-bid areas subject to the adjustments. Beginning January 1, 2017, the fully adjusted fee schedule rates were on average 50 percent lower than the unadjusted rates in these non-bid areas based on the average reduction in payment for all of the items and services subject to the adjustments, weighted by volume.

In 2016, before the fully adjusted fee schedule rates went into effect, blended rates of 50 percent of the amount based on the competitive bid rates and 50 percent of the traditional fee schedule amounts were implemented for the transitional year period. The IRF resumes these blended rates from June 1, 2018, to December 31, 2018, in rural and non-contiguous areas not subject to the CBP. CMS is continuing to engage with stakeholders regarding the CBP, including the national mail-order program, and payment for items and services furnished in non-bid areas. Going forward, CMS will continue to review data and information about rates for DMEPOS items and services, as required under section 16008 of the 21st Century Cures Act. CMS intends to undertake subsequent notice-and-comment rulemaking to address the rates for durable medical equipment and enteral nutrition furnished in 2019 and beyond.

Comments on the rule are due on or before July 9, 2018.

AMRPA Magazine / June 2018 33

Medicare Managed Care Pay to Increase

by More Than 3 Percent in 2019

Highlights: »»

CMS finalized the proposal to apply a 5.90 percent coding pattern adjustment.

»»

CMS is also contemplating a requirement for the adoption of data release platforms by MA plans in 2020.

On April 2, 2018, the Centers for Medicare and Medicaid Services (CMS) released final policy and payment updates to the Medicare Advantage (MA) and Part D programs through the 2019 Rate Announcement and Call Letter. CMS posted the 2019 Advance Notice in two parts, on December 27, 2017, and on February 1, 2018, when the agency also posted the Draft Call Letter.

CMS accepted comments on all proposals through March 5, 2018, and finalized updates to the methodologies used to pay MA plans and Part D sponsors. In March 2018, AMRPA submitted comments to members of Congress on improving access in MA plans in order to increase consumer transparency and access to clinically appropriate medical rehabilitation services at the point of service. (See May issue of AMRPA Magazine to read the comments.)

The per capita cost growth in Medicare Fee-For-Service (FFS) has grown over the past year. Because the MA growth rates are linked to the overall FFS per capita growth rate, the FFS trend carries over to MA plans.

Table 1 below shows the monthly actuarial value of the Medicare deductible and coinsurance for 2018 and 2019. In addition, for 2019, the actuarial value of deductibles and coinsurance is being shown for non-End-Stage Renal Disease (ESRD) only, since the plan bids will not include ESRD benefits in 2019. The data was provided by the CMS Office of the Actuary.

Table 1: Monthly actuarial value of Medicare deductible and coinsurance for 2018 and 2019

1

34 AMRPA Magazine / June 2018

2018

2019

Part A Benefits

$37.16

$36.59

-1.5%

$34.71

1

Part B Benefits

$126.88

$133.57

5.3

$122.91

Total Medicare

$164.04

$170.16

3.7

$157.62

Includes the amounts for outpatient psychiatric charges.

Change

2019 non-ESRD

2019 Part C Risk Adjustment Model

Star Ratings Enhancements

CMS proposed changes to the CMS-Hierarchical Condition Category (HCC) Risk Adjustment model that is used to pay for beneficiaries enrolled in MA plans. For 2019, CMS finalized an updated model that incorporates most of the proposed changes to the Part C risk adjustment model, such as adding mental health, substance use disorder and chronic kidney disease conditions to the risk adjustment model and technical updates including calibrating the model with more recent data, selecting diagnoses with the same method used for encounter data, and supplementing encounter data used in payment with inpatient data submitted to the historical risk adjustment data collection system (the Risk Adjustment Processing System [RAPS]).

Each year, CMS provides updates to the Part C and D Star Ratings through the Call Letter, including new measures and changes in existing measure specifications. Significant changes include adding the following new measures to the 2019 Star Ratings: Statin Use in Persons with Diabetes (Part D) and Statin Therapy for Patients with Cardiovascular Disease (Part C).

CMS calculates risk scores using diagnoses for each beneficiary whether they were enrolled in FFS or Medicare Advantage. Historically, CMS has used MA diagnoses submitted into RAPS. In recent years, CMS began collecting encounter data from MA organizations, which also includes diagnostic information. CMS did not finalize a model that takes into account the number of conditions an individual beneficiary may have in order to provide stakeholders more time to understand its implications, but plans to implement such as model, which it is referring to as the “Payment Condition Count Model” in 2020 in accordance with the 21st Century Cures Act requirements.

For 2019, CMS finalized the proposal to calculate risk scores by adding 25 percent of the risk score calculated using diagnoses from encounter data and FFS diagnoses with 75 percent of the risk score calculated with diagnoses from RAPS and FFS diagnoses. Since the quality of the encounter data has improved, CMS will move forward with the proposed increased percentage of encounter data in the blend. CMS will also calculate the encounter data-based risk scores exclusively with the new risk adjustment model, as proposed, while maintaining use of the current risk adjustment model for calculating risk scores with RAPS data.

Each year, as required by law, CMS makes an adjustment to plan payments to reflect differences in diagnosis coding between MA organizations and FFS providers. In CY 2019, CMS finalized the proposal to apply a 5.90 percent coding pattern adjustment.

2019 Final Call Letter Driving Patient Engagement CMS is encouraging plans to adopt data release platforms for their enrollees that meet or exceed the capabilities of CMS’s Blue Button 2.0 initiative. CMS states that this will enable enrollees in MA plans to connect their claims data to the applications, services and research programs they trust. CMS is continuing to consider a requirement for the adoption of data release platforms by MA plans in 2020.

CMS will remove from the Beneficiary Access and Performance Problems measure.

As has been done in the past, the updated Categorical Adjustment Index values will be finalized in the Call Letter with analyses based on the 2018 Star Ratings data. CMS will implement scaled reductions for data completeness issues for the Part C and D appeals measures that will avoid potentially disparate impacts on plans.

Expanding Health Related Supplemental Benefits CMS also finalized supplemental benefits policy changes to improve patient access to receive additional types of services through their MA plan. Some Medicare Advantage plans offer supplemental benefits so that enrollees have more healthcare benefits and options than what they would receive under the Medicare FFS Program. Medicare Advantage plans use rebate dollars and plan premiums to fund supplemental benefit offerings. The statute limits supplemental benefits to health care benefits; CMS interprets “supplemental healthcare benefit” as an item or service not covered by Original Medicare, that is primarily health related, and for which the Medicare Advantage plan must incur a direct medical cost.

Previously, CMS has not allowed an item or service to be eligible as a supplemental benefit if the primary purpose includes daily maintenance. However, in the final Call Letter, CMS discusses a reinterpretation of the statute to expand the scope of the primarily health-related supplemental benefit standard. Under this reinterpretation, CMS would allow supplemental benefits if they are used to diagnose, prevent or treat an illness or injury, compensate for physical impairments, act to improve the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and health care utilization. The expansion is expected to increase the number of allowable supplemental benefit options and provide patients with benefits and services that may improve their quality of life and health outcomes. CMS has issued a memorandum with additional guidance on the expansion of supplemental benefits.

For more information, see the CMS website.

AMRPA Magazine / June 2018 35

GAO Issues Report on CMS’ Innovation Center Implementation and Performance

Highlights: »»

The Innovation Center estimates that 103,291 providers participated in payment and service delivery models.

»»

The Innovation Center focused on implementing 17 new models and developed preliminary plans for evaluating the effects of each model and for assessing the center’s overall performance.

The Government Accountability Office (GAO) recently updated its 2012 report on the implementation of the Center for Medicare and Medicaid Innovation (Innovation Center), which became operational in November 2010. The Patient Protection and Affordable Care Act (ACA) created the Innovation Center to test new approaches to health care delivery and payment—known as models—for use in Medicare, Medicaid or the Children's Health Insurance Program (CHIP).

Going forward, the Innovation Center indicated that it plans to continue focusing on the use of voluntary participation models and to develop models in new areas, including prescription drugs, Medicare Advantage (MA), mental and behavioral health and program integrity.

In 2012, GAO reported on the early implementation of the Innovation Center and found that, during the first 16 months of operations, the Innovation Center focused on implementing 17 new models and developed preliminary plans for evaluating the effects of each model and for assessing the center’s overall performance.

In the report, GAO: Describes the status of payment and delivery models implemented and the resources used; Describes the center’s use of model evaluations; and Examines the center’s assessment of its own performance.

GAO reviewed the models, evaluation reports for models that have been implemented, and interviewed officials from the Innovation Center and CMS’s Office of the Actuary. GAO incorporated Department of Health and Human Services (HHS) comments in the draft report.

36 AMRPA Magazine / June 2018

Innovation Center Categories for Models The Innovation Center has organized its models into seven categories based on delivery and payment approaches tested and program beneficiaries covered. The seven categories are listed below: Innovation Center Categories 1. Accountable Care

Includes models built around accountable care organizations (ACOs)—groups of coordinated health care providers who are held responsible for the care of a group of patients. The models are designed to encourage ACOs to invest in infrastructure and care processes for improving coordination, efficiency and quality of care for Medicare beneficiaries.

2. Episode-based Payment Initiatives

Includes models in which providers are held accountable for the Medicare spending and quality of care received by beneficiaries during an “episode of care,” which begins with a health care event (e.g., hospitalization) and continues for a limited time after.

3. Initiatives Focused on Medicare-Medicaid Beneficiaries

Includes models focused on better serving individuals eligible for both Medicaid and Medicare in a cost-effective manner.

4. Initiatives Focused on Medicaid and CHIP Populations

Includes models administered by participating states to lower spending and improve quality of care for Medicaid and CHIP beneficiaries.

5. Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models

Includes models where the Innovation Center works with participants to test state-based and locally developed models, covering Medicare beneficiaries, Medicaid beneficiaries, or both.

6. Initiatives to Speed the Adoption of Best Practices

Includes models in which the Innovation Center collaborates with health care providers, federal agencies and other stakeholders to test ways of disseminating evidence-based best practices that improve Medicare spending and quality of care for beneficiaries.

7. Primary Care Transformation

Includes models that use advanced primary care practices— also called “medical homes”— to emphasize prevention, health information technology, care coordination and shared decision-making among patients and their providers.

GAO’s Findings The Innovation Center Implemented 37 Models that Test Varying Delivery and Payment Approaches, and Obligated Over $5.6 Billion As of March 1, 2018, the Innovation Center had implemented 37 models that test new approaches for delivering and paying for health care with the goal of reducing spending and improving quality of care (see Figure 3). These models varied based on several characteristics, including the program covered— Medicare, Medicaid, CHIP or a combination of the three—and the nature of provider participation— voluntary or mandatory. Through fiscal year 2016, the Innovation Center obligated $5.6 billion of its $10 billion appropriation for fiscal years 2011 through 2019.

The Innovation Center has used evaluations of models to inform the development of additional models, to make changes to models as they are implemented, and to recommend models for expansion. For some instances where evaluations have shown reduced spending with maintained or improved quality of care, the Innovation Center has developed new models that build upon the approaches of earlier models, but with adjustments intended to address reported limitations. In addition, the Innovation Center used evaluations to recommend two models to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary for certification for expansion.

Figure 3: Cumulative number of models implemented by the Centers for Medicare and Medicaid Innovation, 2011-2018

Source: GAO analysis of Centers for Medicare & Medicaid Services data. | GAO-18-302

Note: Models were implemented between January 1, 2011 and March 1, 2018. Of the 37 models, the testing period ended in calendar year 2017 or before the 10 models.

The Innovation Center Established Performance Goals and Related Performance Measures and Reported Meeting Its Targets for Some Goals The Innovation Center established performance goals and related measures and reported meeting its targets for some goals in 2015, the latest year for which data were available.

AMRPA Magazine / June 2018 37

Goal 1: Reduce the growth of health care costs while promoting better health and health care quality through delivery system reform.

This goal has three performance measures that focus on ACOs. The Innovation Center reported mixed results in achieving the targets set; it met the targets for two of its three Goal 1 performance measures for 2015. For the remaining measure—the percentage of ACOs that shared in savings—the center did not meet its target during either of the two years for which data were available. Upon examination of the underlying causes, CMS officials stated that the missed target was driven by the high growth in the number of ACOs that were new—and therefore would not yet be expected to achieve a level of savings in which they could share—and not by ACO performance deficits.

As a result, officials decided that no adjustments were required to the Medicare Shared Savings Program (MSSP) or other ACO Models to help improve performance. The Innovation Center set a target for 2016 that was lower than the 2015 target. For 2017, the Innovation Center lowered the expectation for growth compared to previous years, setting a target that was 1 percent higher than the 2016 target. Moving forward, CMS believes that as more ACOs gain experience, more will share in savings. Additionally, the agency expects that with additional performance years, the targets for the measure will become more refined.

Goal 2: Identify, test and improve payment and service delivery models.

This goal has one performance measure, which identifies the number of models that currently generate cost savings while maintaining or improving quality, or improve quality while maintaining or reducing cost. The four models that have met the criteria of the Innovation Center’s Goal 2 are: Pioneer ACO, the Diabetes Prevention Program, the Initiative to Prevent Avoidable Hospitalizations Among Nursing Facilities Residents Phase 1, and lower-extremity joint replacement under the Bundled Payment for Care Improvement (BPCI) program.

Goal 3: Accelerate the spread of successful practices and models.

For this goal, the first performance measure focuses on the number of states developing and implementing a health system transformation and payment reform plan. The second measure focuses on increasing the percentage of active model participants who are involved in Innovation Center or related learning activities. For the second measure, the Innovation Center noted in its report to Congress that although the results for fiscal year 2016 showed a slight decrease in overall participation in Innovation Center or related learning activities, the majority of models performed higher than their individual targets. Several models underperformed, however, bringing down the overall percentage rate.

38 AMRPA Magazine / June 2018

// GAO stated that according to officials the Innovation Center has developed a methodology to estimate a forecast return on investment for the model portfolio, and is in the early stages of refining the methodology and applying it broadly across the portfolio in 2018.

In addition to the Goal 3 performance measures, the Innovation Center identified two related contextual indicators—which according to officials are measures that provide supporting information to help understand trends or other information related to the goal. The first contextual indicator provides a snapshot of Medicare beneficiary participation at a given point in time for all models operational for more than six months. The second contextual indicator provides information to help understand the level of interest and participation among providers in the Innovation Center’s model portfolio.

In fiscal year 2016, CMS reported that over 3.6 million Medicare fee-for service beneficiaries participated in models, representing approximately 9 percent of Medicare fee-forservice beneficiaries. The Innovation Center estimates that 103,291 providers participated in payment and service delivery models.

GAO stated that according to officials the Innovation Center has developed a methodology to estimate a forecast return on investment for the model portfolio, and is in the early stages of refining the methodology and applying it broadly across the portfolio in 2018. As part of the development efforts, the Innovation Center expects to utilize standard investment measures used in the public and private sectors.

The complete report is available on the GAO website.

Health Care Spending Rises as Americans Use Less Care, HCCI Says

Americans used the same amount or less health care in 2016 compared to 2015, but rising prices caused overall spending in 2016 to grow faster than any time in the last five years, according to a report released by the Health Care Cost Institute (HCCI). HCCI’s annual Health Care Cost and Utilization Report analyzes health care spending and utilization from 2012 to 2016 for people up to age 65 with employersponsored health insurance.

For this report, HCCI analyzed data from about 4 billion claims of nearly 40 million individuals. Claims data was taken from four of the largest health insurance providers in the United States representing about 26 percent of the employersponsored insured population.

Over the five-year period studied, prescription drug spending had cumulative growth of 27 percent, despite a flat or decreasing trend in generic drug prices and a decline in utilization of brand prescription drugs. The increased spending was driven by double-digit price increases from 2012 to 2016 for brand prescription drugs.

While the number of emergency room visits rose just slightly, the average price for an emergency room visit grew steadily over the five-year study for a 31.5 percent cumulative increase, driving the increase in outpatient spending.

The average price of surgery also went up, increasing spending for both inpatient and outpatient care. The average price for surgical admissions increased by nearly $10,000 or 30 percent over the five-year study period, despite a 16 percent decline in utilization. The price for outpatient surgery rose more than 19 percent.

Other findings from the study include: Total spending on primary care office visits fell by almost 6 percent over five years due to a decline in the number of visits. This was offset by a 31 percent spending increase on office visits to specialists and a 23 percent increase in visits for preventive care. These trends could be partly attributable to changes in billing practices or in the way people seek care.

Direct out-of-pocket spending by patients increased every year, but at a slower rate than total health care spending, due to a decline in the amount consumers paid out-of-pocket for prescriptions.

Prices for professional services, fees paid to doctors, surgeons and other clinicians, saw the lowest growth and generally the lowest prices overall. This held true across primary and specialty care, except for surgery.

To download the report, see the Health Care Cost Institute website.

AMRPA Magazine / June 2018 39

Latest Research Findings

High-Intensity Exercise May Improve Walking Ability in People with Incomplete Spinal Cord Injuries In a study funded by the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR), researchers examined the relationship between exercise intensity and walking speeds in people with incomplete spinal cord injury (SCI).

Specifically, the researchers wanted to find out whether walking speeds improved more after high-intensity walking exercises than after low-intensity walking exercises.

According to the National Spinal Cord Injury Statistical Center, more than half of people with SCI have an “incomplete� injury, i.e., nerve pathways to control movement below the injury are still partially intact.

Although outcomes vary considerably, some patients may retain the ability to walk. Previous research has shown that stepping or walking exercises, particularly at faster speeds or during difficult tasks (e.g,, climbing stairs or wearing weights) may help them improve speed and endurance while walking.

Study Participants Researchers at the Midwest Regional Spinal Cord Injury Care System Center enrolled 15 people with incomplete SCI in this study. The participants averaged 49 years old (range: 18-75 years) and had their SCI for an average of 7.7 years. All participants could walk independently, some unsupported and others with the use an assistive device like a brace, cane, or walker.

All of the participants went through two walking programs: a low-intensity walking program and a highintensity walking program. Seven of the participants did the low-intensity program first, while the other eight did

40 AMRPA Magazine / June 2018

the high-intensity program first. Each program lasted four to six weeks, and the participants took a four-week break between the two programs.

Each walking program consisted of up to 20 one-hour sessions, done three to five days per week at a training facility. During each program, the participants practiced walking on a treadmill at varying speeds, stepping in different directions or over obstacles, walking on an inclined surface or over ground, and stepping on stairs.

Although the participants in both the low-intensity and highintensity programs did the same exercises, the intensity level varied between the two programs. The intensity was adjusted by adding leg weights or changing the treadmill speed or incline settings. Specifically, for the low-intensity program, the intensity was adjusted until the participant had a heart rate around 60 percent of the maximum for a person their age (about 102 beats per minute for a 50-year-old) or until the participant said the exercise felt “somewhat hard.” For the high-intensity program, the intensity was adjusted until the participant had a heart rate around 70 percent of the maximum for their age (about 119 beats per minute for a 50-year-old) or until the participant said the exercise felt “hard” or “very hard.”

To find out how the low-intensity and high-intensity walking programs affected walking speed, all of the participants met with an assessor four times for fitness tests: at the beginning of the study; after finishing their first walking program; after the fourweek break between programs; and after finishing their second walking program. During each assessment, the participants completed a treadmill speed test to see how quickly they could walk on the treadmill for one minute without needing to stop.

The researchers also measured how quickly the participants could walk when not on a treadmill. To find out how the programs affected the participants’ metabolism, the researchers measured how much oxygen the participants used during the last 30 seconds of their fastest treadmill walk. Finally, participants completed a six-minute walk test to see how far they could walk on a path in a six-minute time period as they would usually walk -- with or without an assistive device.

Findings The researchers found that the participants increased their treadmill speeds more after they completed the high-intensity walking program than after the low-intensity walking program, regardless of which program they did first. Their fastest treadmill speed increased by an average of 25 percent after they completed the high-intensity program, but only 3 percent after the low-intensity program. The participants also increased their fastest speed off the treadmill more after they completed the high-intensity program (19 percent) than after the low-intensity program (10 percent) regardless of which program they did first.

All participants also improved the distance they could walk in six minutes after they completed both programs, with more improvement after the high-intensity walking program (14 percent after high-intensity walking and 7 percent after low-intensity walking). The researchers also found that after the high-intensity walking program, when the participants walked at the same speed as their fastest baseline speed, they used less oxygen than they did before they started the program.

The authors concluded that increasing the intensity of a walking program, without adding more sessions, can increase the benefit of these exercises for people with incomplete SCI. The authors noted that high-intensity exercise like the walking program tested here may help rebuild connections between nerves and muscles that may have been disrupted after injury, making it easier to keep up a faster walking speed. Future research with larger samples may be useful in better understanding the effects of high-intensity exercise on walking abilities in people with incomplete SCI. Citation Bragz, G., et al (2017) Effects of training intensity on locomotor performance in individuals with chronic spinal cord injury: A randomized crossover study. Neurorehabilitation and Neural Repair, 31(10-11), 944-954. This article is available from the NARIC collection under Accession Number J77953.

Source: National Rehabilitation Information Center (NARIC) Research in Focus

Study Examines Differences in Preventive Care in Adults With and Without Disabilities In a recent study funded by the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR), “Access to preventative services for working-age adults with physical limitations,” researchers examined whether adults with disabilities were more or less likely than adults without disabilities to access preventative care services such as blood pressure checks, flu shots or annual dental checkups.

The study also sought to examine other factors associated with patients’ ability to access these services since adults with disabilities, especially physical disabilities, are more likely to develop long-term health problems than adults without disabilities.

AMRPA Magazine / June 2018 41

Methods The researchers at the Collaborative on Health Reform and Independent Living (CHRIL) analyzed data from the Medical Expenditures Panel Survey (MEPS). The respondents included 75,145 adults aged 18-64 who completed the MEPS between 2003 and 2012. The respondents were asked whether or not they had a disability, and to describe the types of limitations they experienced if they did have a disability.

The respondents were classified as having a physical disability if they said they had difficulty walking, climbing stairs, bending, lifting or grasping objects. The respondents were classified as having a nonphysical disability if they said they had other limitations but did not have difficulty with any of the above tasks.

A third group of respondents reported not having any disability.

The respondents were asked whether or not they had gotten a blood pressure check, a flu shot or a dental checkup in the past year. They also answered several demographic questions including their gender, level of education, income, medical or dental insurance coverage, as well as chronic health conditions they had (such as high blood pressure, diabetes, arthritis or emphysema). Finally, the respondents were asked whether or not they had a “usual source of care,” — a healthcare professional they could see on a regular basis (besides going to the emergency room).

Findings The researchers found that among the respondents: Adults with disabilities were more likely to get their blood pressure checked than adults without disabilities: 92 percent of the respondents with physical disabilities and 83 percent of the respondents with nonphysical disabilities had gotten a blood pressure check in the last year, compared with 70 percent of the respondents without disabilities.

Adults with physical disabilities were more likely to have received an annual flu shot: 40 percent of the respondents with physical disabilities and 30 percent of the respondents with nonphysical disabilities had received a flu shot, compared with 23 percent of the respondents without disabilities.

42 AMRPA Magazine / June 2018

Adults with disabilities were more likely to have medical insurance: 80 percent of the respondents with physical disabilities and 77 percent of the respondents with nonphysical disabilities reported having insurance, compared to 76 percent of the respondents without disabilities.

However, adults with disabilities were less likely to have an annual dental checkup than adults without disabilities: 45 percent of the respondents with physical disabilities and 52 percent of the respondents with nonphysical disabilities had had a dental checkup within the past year, compared with 59 percent of the respondents without disabilities.

Adults with disabilities were less likely to have dental insurance: only 38 percent of the respondents with physical disabilities and 48 percent of the respondents with nonphysical disabilities reported having dental insurance, compared to 67 percent the respondents without disabilities.

When the researchers compared the likelihood of different patient groups receiving preventive services, they found that: Regardless of disability status, adults with more than one chronic health condition were more likely to get preventive care but less likely to get dental checkups than those without these conditions.

Regardless of disability status, women were more likely to get all three preventive services than men.

Adults with at least a college degree and family income at least four times the federal poverty level were more likely to get the three preventive services than the respondents with less than a high school degree or family income below the federal poverty level.

Regardless of disability status, adults with a usual source of care were more likely to get all three preventive services than those without a usual source of care.

The findings indicate that working-age Americans with disabilities receive more of some preventive services than working-age Americans without disabilities, with the exception of dental care.

Although a majority of Americans with disabilities have some type of health insurance, less than half of adults with disabilities have dental insurance.

The authors also noted that having a primary care provider, or other usual source of care, greatly increased the likelihood that working-age individuals with and without disabilities would receive timely access to preventive care. However they stated that more research is needed to identify healthcare plans that promote access to a consistent care provider for persons with disabilities. Further research is also needed to examine factors that can improve the physical accessibility of healthcare facilities.

Citation Gimm, G., Wood, E., and Zanwar, P. (2017) Access to preventative services for working-age adults with physical limitations. Archives of Physical Medicine and Rehabilitation, 98, 2442-2448. The article is available from the NARIC collection under Accession Number J7740.

Source: National Rehabilitation Information Center (NARIC) Research in Focus

AMRPA Magazine / June 2018 43

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44 AMRPA Magazine / June 2018

AMRPA wants to make sure that our members are active participants in shaping their federal representation in Congress. To do so, we are continuing to provide updates on upcoming elections as part of our civic engagement series. Below you’ll find information on primaries taking place in June and August, as well as additional online resources where you can find more information on voting and your Congressional representatives.

The following states will be holding primary elections in June, for a total of 17 primary elections:

Alabama – June 5, 2018

South Dakota – June 5, 2018 One open House seat is up for election.

No Senate seats are on the ballot.

Maine – June 12, 2018 Maine two House seats in the delegation. Both incumbents are running for reelection.

One Senate seat up for election.

Nevada – June 12, 2018 Four House seats are up for election: two incumbents and two open seats.

One Senate seat is on the ballot.

Seven House seats are up for election. All incumbents are running for reelection.

No Senate seats are on the ballot.

North Dakota – June 12, 2018

California – June 5, 2018

South Carolina – June 12, 2018

California has 53 House seats in the delegation: 51 incumbents and two open seats.

One Senate seat is up for election.

Iowa – June 5, 2018 There are four House seats up for election. All incumbents are running for reelection.

No Senate seats are on the ballot this year.

Montana – June 5, 2018 One House seat is up for election. The incumbent is running for reelection.

One Senate seat up for election.

New Jersey – June 5, 2018 New Jersey has 12 House seats in the delegation: 10 incumbents and two open seats.

One Senate seat up for election.

New Mexico – June 5, 2018 Three House seats are up for election: one incumbent and two open seats.

One Senate seat up for election.

North Dakota has one open House seat up for election.

One Senate seat is up for election.

Seven House seats are up for election: six incumbents and one open seat.

No Senate seats are up for election.

Virginia – June 12, 2018 Virginia has 11 House seats in the delegation: 10 incumbents and one open seat.

One Senate seat is up for election.

Colorado – June 26, 2018 Seven House seats are up for election: six incumbents and one open seat.

No Senate seats are on the ballot.

Maryland – June 26, 2018 Eight House seats are up for election: seven incumbents and one open seat.

No Senate seats are on the ballot.

Mississippi – June 26, 2018 Four House seats are up for election: three incumbents and one open seat.

There are two Senate seats up for election. One incumbent and one open seat.

AMRPA Magazine / June 2018 45

Oklahoma – June 26, 2018

Vermont – August 14, 2018

Oklahoma has five House seats in the delegation: four incumbents and one open seat.

No Senate seats are on the ballot.

Vermont has one House seat. The incumbent is running for reelection.

One Senate seat is on the ballot.

Utah – June 26, 2018

Wisconsin – August 14, 2018

Utah has four House seats up for election. All incumbents are running for reelection.

One open Senate seat is on the ballot.

Eight House seats are up for election: seven incumbents and one open seat.

One Senate seat is on the ballot.

The following states will be holding primary elections in August, for a total of 14 primary elections:

Alaska – August 21, 2018

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

One Senate seat is on the ballot.

Kansas – August 7, 2018 Kansas has four House seats in the delegation: three incumbents and one open seat.

No Senate seats are on the ballot.

Michigan – August 7, 2018 Michigan has 14 House seats up for election: 12 incumbents and two open seats.

One Senate seat is on the ballot.

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

One Senate seat is on the ballot.

Washington – August 7, 2018 Washington has 10 House seats in the delegation: nine incumbents and one open seat.

One Senate seat is on the ballot.

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

One Senate seat is on the ballot.

Alaska has one House seat. The incumbent is running for reelection.

No Senate seats are on the ballot.

Wyoming – August 21, 2018 Wyoming has one House seat. The incumbent is running for reelection.

One Senate seat is on the ballot.

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

One Senate seat is on the ballot.

Florida – August 28, 2018 Florida has 27 seats in the delegation: 23 incumbents and four open seats.

One Senate seat is on the ballot.

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, please contact Catherine Beal at cbeal@amrpa.org or (202) 860-1006.

For more information on your federal representatives, visit the following websites:

Connecticut – August 14, 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.

Five House seats are up for election: four incumbents and one open seat.

One Senate seat is on the ballot.

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

Minnesota – August 14, 2018 Eight House seats are up for election: six incumbents and two open seats.

One Senate seat is on the ballot.

46 AMRPA Magazine / June 2018

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48 AMRPA Magazine / June 2018