AMRPA Magazine - June 2019 by AMRPA

June 2019 â&#x20AC;¢ Vol. 22, No.6

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June 2019 â&#x20AC;˘ Vol. 22, No. 5

The official publication of the American Medical Rehabilitation Providers Association (AMRPA) Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Director Kate Beller, JD AMRPA Executive Vice President for Government Relations and Policy Development Carolyn Zollar, MA, JD AMRPA Senior Policy Counsel Mimi Zhang AMRPA Director of Payment Innovation, Quality and Research Patricia Sullivan AMRPA Senior Editor Matthew Matyjek AMRPA Communications and Public Affairs Coordinator

Table of Contents Letter from the Chair

Legislative Update

Risk of Prior Authorization of IRF Care Spreads to Traditional Medicare

Rehabilitation Nursing Documentation

CMS Releases FY 2020 IRF PPS Proposed Rule

CMS Proposes Changes for Acute-Care and Long-term Care Hospitals

OIG Recommends Improvements to Lower Deficiencies at Nursing Homes

Florida Hospital Finds Success with Innovative Discharge Preparation

CARF to Add Screen for Suicide Risks to Assessment Standards

CMS Administrator Outlines Recent Burden Reduction Efforts

CMS Launches New Payment Models Focused on Primary Care

CMS, Treasury Department Seeking Comments for Waiver Concepts for ACA State Markets

Brian McGowan AMRPA Design and Layout AMRPA Magazine, Volume 22, 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. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color. Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Julia Scott, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1110, Email: jscott@amrpa.org. Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content ÂŠ2019 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Kellen Company. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 750, Washington, DC 20045

AMRPA Magazine / June 2019

Letter from the Chair

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

Addressing Barriers to Discharge A recent article in Modern Healthcare addressed discharge planning in a hospital setting (Castellucci, 2019). The article highlighted the experience at a children’s hospital to reduce its length of stay by working on barriers to discharge early in the admission cycle. Yet the message translates well to acute and post-acute levels of care. External barriers to discharge are those that the health care facility cannot readily control. External barriers include insurance pre-admission authorizations, availability and scope of services in the community, and access to post-discharge health services. Some external barriers could be grouped as social determinants, such as family support, housing and transportation. It is reassuring to note that the Centers for Medicare and Medicaid Services, through its Accountable Health Communities Models (reported at innovation. cms.gov/initiatives/ahcm/) are looking at improving health-related social determinants that could reduce cost and enhance health outcomes. For internal barriers to discharge, Castellucci (2019) recounted how 78 percent of discharge issues at the hospital were due to barriers that the hospital could influence. A taskforce felt that many of these barriers could be better managed internally. The hospital began a process to identify discharge issues within the first hours of admission and then throughout the patient’s stay. These efforts were met with success. Early and frequent discharge planning should be common practice in all appropriate levels of care. Acute care hospitals need to view the post-acute care continuum as an integrated component of their system of care. If post-acute care is viewed as an isolated, disconnected service and only considered well into the trajectory of the patient’s hospital stay, barriers will not be addressed on a timely basis. If length of stay, cost of care and patient needs are central to a hospital or health system’s performance metrics, then consideration of the patient’s needs post-discharge should be addressed on admission and throughout the patient’s stay. Even discharge planning between post-acute care settings needs to occur early in the process in order to provide the scope of services needed. Linking post-acute care providers to patient needs will assist in reducing post-discharge complications and improve outcomes (Armstrong & Jhu, 2016). Involving post-acute care providers early in the patient admission is not easy, but it could be accomplished with early, ongoing and open communication with representatives between the various levels of care.

References

Castellucci, M. (2019, Apr 19). Preparing for discharge shortly after admission to reduce length of stay. Modern Healthcare, 49 (17), p. 30. Armstrong, R & Jhu, E. (2016, Apr 21). Post-acute care integration should be a priority for your hospital. Retrieved from https://www.beckershospitalreview.com/finance/post-acute-care-integration-should-be-a-priority-for-your-hospital.html

AMRPA Magazine / June 2019

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AMRPA Magazine / June 2019

Legislative Update

Akin Gump Hosts Policy Roundtable Focused on Health Care Costs On May 9, 2019, Akin Gump Strauss Hauer & Feld LLP hosted a health policy roundtable on drug pricing, surprise billing and other health care cost initiatives facing the first session of the 116th Congress. Gov. Tommy Thompson, former Secretary of the U.S. Department of Health and Human Services and former governor of Wisconsin, moderated a panel discussion with:

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

Highlights: »»

»»

he House Appropriations Committee T reported out an almost $12 billion Fiscal Year (FY) 2020 Labor, Health and Human Services, Education and Related Agencies spending bill. ongressional leadership continue C negotiations on how to raise the budget caps, before automatic sequestration spending cuts would take effect in January 2020. ealth care costs transparency issues, H including surprise billing and prescription drug pricing, continue to drive policy discussions on Capitol Hill. n April 17, the Centers for Medicare O and Medicaid Services released the FY 2020 Inpatient Rehabilitation Facility (IRF) Prospective Payment System Proposed Rule, including a proposed 2.3 percent update in IRF payments.

Elizabeth Jurinka, Chief Health Advisor to Senate Finance Committee Ranking Member Ron Wyden (D-OR) Katie Meyer, Senior Policy Advisor to House Republican Leader Kevin McCarthy (R-CA) Wendell Primus, Senior Policy Advisor to Speaker Nancy Pelosi (D-CA) Dr. Karen Summar, Health Policy Director to Senate Finance Committee Chair Chuck Grassley (R-IA). These key health staff shared insights and perspectives on issues and dynamics in play in the 116th Congress. FY 2020 Proposed IRF Rule Updates Revised Case-Mix Groups CMS released the FY 2020 Inpatient Rehabilitation Facility (IRF) Prospective Payment System Proposed Rule on April 17. Overall, CMS projects payments to IRFs will increase by 2.3 percent (or $195 million) in FY 2020. The proposed rule provides updated data for the revised case-mix groups that are set to take effect in FY 2020. CMS also clarifies that the decision of whether a physician qualifies as a “rehabilitation physician” should be made by IRFs. CMS is also proposing to adopt two new IRF quality measures related to the transfer of health information. Comments on the proposed rule are due June 17, 2019. FY 2020 Appropriation Bills Move Forward Despite No Long-Term Funding Agreement With no bipartisan agreement on spending levels for Fiscal Year (FY) 2020, House Democrats are nonetheless moving ahead with individual appropriations bills for the coming fiscal year. Appropriations Chair Nita Lowey (D-NY) has said she will follow the $664 billion defense limit and $631 billion non-defense limit in legislation (H.R. 2021) she authored with House Budget Chair John Yarmuth (D-KY). Plans to bring that legislation to the floor before the April recess were scrapped due to objections by Members of the Progressive Caucus. However, House Democrats adopted an informal “deeming resolution” (H.Res. 293) to set spending targets that correspond to the total levels in H.R. 2021. The House Appropriations Committee is proceeding with markups, with the hope that the quick start will give Democrats some leverage in spending cap negotiations. The Senate has yet to settle on overall spending targets, pending action on a disaster

AMRPA Magazine / June 2019

aid package. While the Senate Budget Committee approved a Budget Resolution last month, Senate Republican leaders do not plan to bring the measure to the floor. On May 8, 2019, the House Appropriations Committee voted 30-23 to approve the Fiscal Year (FY) 2020 Labor, Health and Human Services, Education and Related Agencies (Labor-HHS) spending measure on a party-line vote. The bill includes $189.9 in discretionary funding, an increase of $11.8 billion over the 2019 enacted level and $48 billion higher than the president’s FY 2020 budget request. The marathon markup on Wednesday included votes on amendments related to abortion, short-term health plans, and unaccompanied migrant children. The Appropriations Committee released its report accompanying the spending bill prior to the vote. The Committee Report contains provisions of interest to AMRPA members, including language around prior authorization. The Report states: “The Committee is aware that Medicare Advantage (MA) plans have increased the use of prior authorization (PA), which requires physicians and other health care providers to obtain advance approval from the plan before services can be delivered to patients. While PA is a valid utilization review tool to ensure appropriate care, health care provider experience and research studies demonstrate that inappropriate use of PA causes significant patient care delays, administrative costs and workflow disruptions. The Committee directs CMS to improve Medicare beneficiary timely access to care, increase transparency, and reduce the burdens on patients and providers by providing guidance to MA plans on their use of PA. Specifically, CMS should require MA plans to selectively apply PA requirements, excluding from PA those services that align with evidencebased guidelines and have historically high PA approval rates. In addition, CMS should increase transparency by requiring MA plans to report annually to the Secretary a list of items and services that are subject to PA, the percentage of PA requests approved, and the average time for approval. Finally, the Committee encourages CMS to work with stakeholders to increase the use of electronic prior authorization.” AMRPA’s Washington lobbyists have alerted key Congressional offices on our support for this language. The Labor-HHS Report also includes language encouraging the National Institute of Neurological Disorders and Stroke (NINDS) to prioritize studies that help develop interventions to reduce health disparities in stroke and to advance promising stroke prevention, treatment and rehabilitation research, including endovascular therapy and tele-rehabilitation. The committee also requests that NINDS work with all relevant parts of the National Institutes of Health (NIH) including the National Institute on Aging (NIA) to support a robust and coordinated portfolio of traumatic brain injury (TBI) research that explores all promising avenues to facilitate functional repair of damaged circuitry in TBI, including research on regenerative medicine and neuroplasticity.

The committee calls for a $10 million increase to improve State Survey and Certification frequency rates for nursing homes, home health agencies, and hospice facilities, and a $37 million increase for Home and Community-Based Supportive Services, which provides formula grants to states and territories to help seniors remain independent in their homes. Negotiations between House and Senate leaders and appropriators will likely continue for several months, with the hope of reaching a deal before the Treasury Department’s “extraordinary measures” are exhausted around the end of September. While the White House has called for swift passage of a spending agreement, the president is urging Senate Majority Leader Mitch McConnell (R-KY) not to agree to any measure that raises the budget caps. If Congress and the White House are unable to reach agreement on new budget caps before the deadline, automatic sequestration spending cuts would take effect in January. Home Health Legislation Introduced in the House On May 8, Rep. Terri Sewell (D-AL) and a bipartisan group of lawmakers introduced the Home Health Payment Innovation Act of 2019 (H.R. 2573). The legislations aims to preserve access to home health services by preventing dramatic cuts to home health agencies in 2020. Specifically, the bill would ensure that any behavioral adjustment under the Patient-Driven Groupings Model (PDGM) is based on actual rather than assumed behavioral changes. H.R. 2573 would also provide a phase-in for any rate increases or decreases. The Senate companion (S. 433) was introduced earlier this year by Sens. Susan Collins (R-ME) and Doug Jones (D-AL). White House Hosts Another Surprise Billing Discussion President Trump spoke on surprise billing at a White House event on May 9, announcing four principles to guide Congress in developing legislation on the issue: Out-of-network balance billing should be prohibited for emergency care; Patients should be given prices and out-of-pocket costs in advanced of scheduled, non-emergency care; Patients should not receive bills from out-of-network providers that they did not choose themselves; and Legislation should protect patients without increasing federal expenditures or reducing patient choice. The president was joined by Secretary Azar, Members of Congress, patients and physicians. Several individuals who had been subject to surprise billing practices shared their experiences and gave their support for a legislative effort to address the problem. Sen. Lamar Alexander (R-TN), Chair of the Health, Education, Labor and Pensions (HELP) Committee, said he hopes to send the president legislation in July. The president also previewed a major announcement on health care transparency in the next few weeks, though he did not offer additional details. Drug Pricing Legislation Remains Priority Policy Issue On May 7, the Senate Judiciary Committee held a hearing to examine how patent rights and exclusivity may contribute to higher drug prices and delayed generic competition. Sen. John Cornyn (R-TX) argued that the filing of so many patents on

AMRPA Magazine / June 2019

certain drugs have an anti-competitive effect on the market. On May 9, Sens. Cornyn and Richard Blumenthal (D-CT) introduced legislation to give the Federal Trade Commission (FTC) greater ability to challenge drug companies who are “gaming” the patent system. The House on May 8 passed two bills to support generic and biosimilar drug competition. The Orange Book Transparency Act (H.R. 1503), sponsored by Rep. Robin Kelly (D-IL), and the Purple Book Continuity Act (H.R. 1520), sponsored by Rep. Anna Eshoo (D-CA), would ensure timely and accurate updates to the Food and Drug Administration’s (FDA) list of patents for approved drug and biological products. H.R. 1503 and H.R. 1520 passed by votes of 422-0 and 421-0, respectively. As we go to press the House is poised to consider a legislative package (H.R. 987) that combines three committee-approved drug pricing bills with four Affordable Care Act (ACA)-related measures. The drug pricing bills are H.R. 965, the CREATES Act; H.R. 1499, the Protecting Consumer Access to Generic Drugs Act; and H.R. 938, the BLOCKING Act. While the prescription drug pricing bills enjoy bipartisan support, Republicans are likely to oppose the package over the inclusion of the ACA bills. Washington commentators seem to agree that a bipartisan agreement on drug pricing is possible, given the number of bills that have already passed out of Committee this year, though it may be too soon to speculate about the scope of such a package. The Centers for Medicaid and Medicaid Services (CMS) Actuary and the Congressional Budget Office (CBO) will be valuable in providing analyses to determine which proposals will bring down drug costs the most without hurting innovation. Importation proposals likely would not be part of a drug pricing package. Congress could use repeal of the administration’s drug rebate rule to garner significant savings that would be helpful in passing a broader deal. The House reportedly is interested in using savings to advance changes to Medicare Part D. The Senate legislation aims to advance drug pricing changes in Medicare Parts B and D and Medicaid. Senate Finance Committee Chair Chuck Grassley (R-IA) and Ranking Member Ron Wyden (D-OR) are working together on drug pricing, with the goal of marking up legislation in mid-June. The Committee is considering inclusion of proposals such as the CREATES Act, pay-for-delay legislation, Prescription Providing for the People Act of 2019, and others relating to improvements in transparency and preventing “sham” citizen petitions. Senators aim to produce a package of policies that they can easily explain to the American public and will result in meaningful improvements in patients’ lives. This effort could be combined with that of the Senate Health, Education, Labor and Pensions (HELP) Committee, where Chair Lamar Alexander (R-TN) has been more focused on surprise billing and broader health care cost issues. A most significant development to mention is that Speaker Nancy Pelosi (D-CA) is developing an arbitration model for drug pricing that would follow a period of government negotiation and reportedly reflect the baseball arbitration model; specific drugs would be targeted for sharp international price disparities, and 8

AMRPA Magazine / June 2019

the arbitration would be binding across all payers. The speaker is in discussions with the White House and is perceived to be committed to moving the bill through regular order in the House. There appears to be skepticism in Washington that Congress would be able to advance any drug importation proposals, given most Republicans oppose importation. Nonetheless, the concept continues to resonate with many Americans who feel it is unfair that drug prices are significantly lower in Canada and other Western countries. While the administration’s International Pricing Index (IPI) model has detractors on both sides of the aisle, there appears to be recognition that there needs to be some pricing solution that distributes the cost of innovation more equitably and lowers prices relative to other countries. Several FY 2020 Payment Regulations Released The FY 2020 Hospice Payment Rate Update Proposed Rule was released on April 19. The Centers for Medicare and Medicaid Services (CMS) is proposing a payment rate update of 2.7 percent ($540 million) for FY 2020. CMS proposes to requires that hospices give a list of and rationale for which items, drugs, and services the providers believe are unrelated to beneficiaries’ terminal illnesses to the beneficiaries, providers, and Medicare contractors. The rule solicits comments on how the hospice benefit interacts with Medicare Advantage and Accountable Care Organizations (ACOs), as well as what other models CMS should consider to improve Medicare. Comments on the proposed rule are due June 18, 2019. CMS issued its FY 2020 Skilled Nursing Facility (SNF) Prospective Payment System Proposed Rule on April 19. CMS estimates payments to SNFs will increase by 2.5 percent (or $887 million) in FY 2020. As was previously finalized, CMS will proceed with implementation of the Patient Driven Payment Model (PDPM), which is configured based on patient characteristics rather than therapy minutes. The proposed rule also redefines group therapy to include groups of two to six patients, rather than the current definition of exactly four patients. CMS proposes to add two new quality measures to the SNF Quality Reporting Program related to the interoperability of electronic health records. Comments on the proposed rule are due June 18, 2019. On April 23, CMS released its FY 2020 Hospital Inpatient Prospective Payment System (IPPS) Proposed Rule. CMS is proposing to update the IPPS wage index to increase payments for rural hospitals. Overall, CMS estimates a 3.7 percent (or $4.7 billion) increase in payments for acute care hospitals for FY 2020. CMS proposes distributing $8.5 billion in uncompensated care payments in FY 2020, an increase of $216 million from FY 2019. The rule proposes several changes to the Hospital Inpatient Quality Reporting Program, including the addition of two new opioid-related quality measures. Notably, the rule also proposes a new technology add-on payment pathway for medical devices that are part of the FDA’s Breakthrough Devices Program. Comments on the proposed rule are due June 24, 2019.

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AMRPA Magazine / June 2019

Risk of Prior Authorization of IRF Care Spreads to Traditional Medicare

Within the past year, the Trump administration has proposed expanding the use of prior authorization (PA) to inpatient rehabilitation hospital and unit (IRF) services in the feefor-service (FFS) or “traditional Medicare” program—a move that would impede patient access to care and comprise patient medical and functional outcomes. This article provides a summary of those efforts and the American Medical Rehabilitation Providers Association’s (AMRPA) campaign to protect patients against the detrimental effects of prior authorization.

Peter W. Thomas, JD, Principal, The Powers Law Firm

Leela Baggett, JD, Associate, The Powers Law Firm

Recent Developments Regarding Prior Authorization On September 27, 2018, the Office of Inspector General for the Department of Health and Human Services (OIG) issued a report titled, Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements.1 The report found an astounding 84 percent error rate for IRFs based on a sample of 2013 claims. This error rate was extrapolated to an estimated $5.7 billion in overpayments to IRFs paid under the traditional Medicare in 2013. According to the OIG, the high error rate of payment occurred, in part, because the Centers for Medicare and Medicaid Services (CMS) does not utilize prior authorization for IRF admissions in the Medicare Part A FFS program. As a result of the audit findings, the OIG recommended, among other things, that CMS reevaluate the IRF payment system, which could include a demonstration project requiring preauthorization for IRF stays under traditional Medicare modeled on Medicare Advantage practices. In its written comments to the OIG, CMS concurred with this recommendation. This led AMRPA and many others in the IRF community to fear that CMS would include a new prior authorization requirement in the IRF prospective payment system (PPS) proposed rule for fiscal year 2020, which CMS issued on April 24, 2019.2 Fortunately, this fear did not materialize, as CMS decided not to propose prior authorization in its IRF Medicare policies for fiscal year 2020. While many considered this a dodged bullet, President Trump’s Fiscal Year 2020 Budget called for expanding the Medicare program’s authority to use prior authorization in the traditional Medicare program, patterned off of Medicare Advantage (MA) prior authorization, and included application to IRF services.3 The OIG report and the president’s fiscal year 2020 budget are highly concerning developments. Prior authorization leads to improper delays, transfers to less intensive settings of rehabilitation care that can compromise patient outcomes, and denials in care

OIG, U.S. Dep’t of Health & Human Servs., No. A-01-15-00500, Many Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements (2018).

Medicare Program; Inpatient Rehabilitation Facility (IRF) Prospective Payment System for Federal Fiscal Year 2020 and Updates to the IRF Quality Reporting Program, 84 Fed. Reg. 17,244 (Apr. 24, 2019), https://www.govinfo.gov/content/pkg/FR-2019-04-24/pdf/2019-07885.pdf.

OMB, Budget of the United States Government, Fiscal Year 2020, 44 (Mar. 11, 2019), https://www.whitehouse.gov/wp-content/uploads/2019/03/budget-fy2020.pdf.

10 AMRPA Magazine / June 2019

that can cause irreparable harm to beneficiaries. AMRPA believes prior authorization in the MA program should be improved dramatically, and strongly opposes IRF prior authorization in the traditional Medicare program. AMRPA has partnered with other rehabilitation stakeholders to mount a strong response against the President’s Fiscal Year 2020 Budget proposal and the OIG’s recommendations in its October 2018 report. Prior Authorization in the Context of Medicare Advantage Medicare Advantage enrollees are legally entitled to the same benefits as traditional Medicare beneficiaries, but Medicare Advantage plans routinely use a variety of mechanisms to control utilization, including the use of proprietary coverage guidelines and the use of prior authorization. On September 25, 2018, the OIG issued a report raising serious concerns about the use of prior authorization by Medicare Advantage Organizations.4 The OIG found that in 2016, Medicare Advantage Organizations denied one million prior authorization requests and 36 million payment requests. The OIG found that Medicare beneficiaries and providers won 75 percent of their appeals during 2014 to 2016. Of the overturned denials, 82 percent were for payment to providers for services that the beneficiary already received, and 18 percent were for prior authorization of services that the beneficiary had not yet received. In 2015, CMS cited 56 percent of audited Medicare Advantage Organizations contracts for two types of violations concerning inappropriately denied requests for prior authorization of services and/or payment. According to the report, these statistics “raise concerns that some beneficiaries and providers may not be getting services and payment that [Medicare Advantage Organizations] are required to provide.”5 The OIG recommended that CMS monitor Medicare Advantage Organizations with low rates of approved preauthorization requests. In response to this OIG report, a bipartisan group of 103 members of Congress wrote a letter to CMS requesting that it “provide guidance to [Medicare Advantage] plans regarding the use of prior authorization to ensure that these requirements to do not create inappropriate barriers to care for Medicare patients.”6 These members of Congress were “concerned that patients may be encountering barriers to timely access to care that are caused by onerous and often unnecessary prior authorization requirements.”7 This letter followed on the heels of another letter to CMS Administrator Seema Verma from Republican leadership in the House Committee on Ways and Means expressing concern that prior authorization is “causing unnecessary delays in patient care.”8 In light of the OIG’s findings on the abuses of prior authorization by Medicare Advantage Organizations, AMRPA and other stakeholders have questioned the appropriateness of expanding prior authorization to traditional Medicare IRF services.

// In 2015, CMS cited 56 percent of audited Medicare Advantage Organizations contracts for two types of violations concerning inappropriately denied requests for prior authorization of services and/or payment. Prior Authorization in the Context of IRF Care IRFs provide unique medical and rehabilitation services to patients recovering from surgical procedures, strokes, spinal cord injuries, brain injuries, amputations, hip fractures, and many other debilitating conditions that impact a beneficiary’s ability to perform activities of daily living. In order to ensure that only appropriate patients are admitted to IRFs, Medicare imposes stringent patient screening criteria. This includes a requirement to conduct a comprehensive preadmission screening within the 48 hours immediately preceding the IRF admission. The preadmission screening serves as the basis for the initial determination of whether or not the patient meets the Medicare requirements for IRF admission. In addition, the patient must need an interdisciplinary approach to care and be stable enough at admission to participate in intensive rehabilitation. There must be a “reasonable expectation” that the patient will need multidisciplinary therapy, intensive rehabilitation, and supervision by a rehabilitation physician. These requirements serve as a de facto form of preauthorization, one that is clinician driven at the point of service and does not delay or deny medically necessary care. This stands in stark contrast to MA plans that often take days to approve a prior authorization request, especially when the patient is admitted on a Friday afternoon or weekend or holiday. Appeals of PA denials extend the admission decision further as the acute care hospital discharge planner looks for alternative settings to take the patient and clear an acute care hospital bed that is in high demand. In this scenario, the patient is the big loser, never gaining access to the appropriate level of rehabilitation care to which he or she is entitled. Worse yet, this situation creates a sentinel effect, where acute care hospital discharge planners

OIG, U.S. Dep’t of Health & Human Servs., No. OEI-09-16-00410, Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials (2018).

Id. at 17. Letter from David P. Roe, U.S. House of Representatives, et al. to Seema Verma, Administrator, CMS (Oct. 10, 2018). Id. Letter from the Kevin Brady, Chairman, Committee on Ways and Means & Peter Roskam, Chairman, Subcommittee on Health, Committee on Ways and Means to Seema Verma, Administrator, CMS (Sept. 4, 2018).

6 7 8

AMRPA Magazine / June 2019 11

realize the barriers to IRF admissions and pre-emptively divert the patient to a skilled nursing or home health setting without the patient even realizing they quality for an IRF level of care. Subjecting Medicare FFS beneficiaries to prior authorization modeled on the Medicare Advantage program ignores the rigorous coverage requirements governing IRF admission. As evidenced by the OIG’s report on Medicare Advantage Organizations, prior authorization jeopardizes access to medically necessary IRF care. The Medicare Payment Advisory Commission (MedPAC), an independent legislative branch agency that provides Congress with analysis and advice on the Medicare program, found that Medicare Advantage enrollees in 2015 were admitted to IRFs at approximately one-third the rate of traditional Medicare beneficiaries.9 This wide discrepancy in admission rates is due, in part, to the routine use of prior authorization in the MA program. MedPAC noted that the “disparity in use rates suggest that [Medicare Advantage] plans are more selective in the types of cases they authorize to receive care in IRFs.”10 This evidence suggests that prior authorization inappropriately denies Medicare Advantage enrollees’ access to IRF care. Expanding prior authorization to traditional Medicare IRF patients would construct similar barriers. In addition to outright denials, prior authorization inevitably delays the decision to transfer the patient out of an acute care hospital to the IRF. Such delays are often tantamount to outright denials as discharge planners have no choice but to move patients out of the acute care hospital. Denying or delaying medically necessary IRF care has a profound impact on patients, hindering their medical and function outcomes, independence and long-term quality of life. Prior authorization also places the patient at a higher risk of hospital readmission. After analyzing multiple post-acute care settings, MedPAC found that IRFs have lower readmission rates than skilled nursing facilities.11 Low readmission rates are an important indicator of quality care.

Efforts to Protect Patients As previously stated, AMRPA has partnered with other stakeholders in the community to vehemently oppose prior authorization from being implemented in the traditional Medicare program, as well as to improve the prior authorization process in the MA program. AMRPA has joined forces in coalition with the American Academy of Physical Medicine and Rehabilitation as well as the Federation for American Hospitals to draft a joint response to the OIG report and to meet with senior OIG and CMS officials. These organizations are planning a meeting soon with the Office of Management and Budget, the White House agency responsible for many of the budget proposals in this year’s FY 2020 budget. AMRPA is also developing policy proposals to improve prior authorization to ensure it does not create barriers to IRF care in the future. AMRPA has also led a grassroots strategy within its membership to encourage AMRPA members to inform their members of Congress of the negative effects of prior authorization on Medicare beneficiaries. And the Coalition to Preserve Rehabilitation (CPR Coalition), which AMRPA supports, is a strong advocate against prior authorization, especially in the traditional Medicare program. These efforts along with like-minded health care organizations are putting pressure on Congress to legislate. In fact, AMRPA is working with Reps. Mike Kelly (R-PA), Susan DelBene (D-WA), Roger Marshall (R-KS), and Ami Bera (D-CA) who are crafting bipartisan legislation to improve prior authorization, particularly in the Medicare Advantage program. This legislation, likely to be introduced in the near future, would reduce the use of prior authorization, improve transparency in the program, and expedite the prior authorization process through automation. AMRPA continues to treat prior authorization as a high priority and is expected to continue to do so throughout the 116th Congress.

MedPAC, Report to The Congress: Medicare Payment Policy, 272 (Mar. 2017), http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf.8).

Id.

edPAC, Uniform Outcome Measures for Post-Acute Care, 6 (Apr. 5, 2018), http://medpac.gov/docs/default-source/default-document-library/pac-outcomeM measures-handouts.pdf.

12 AMRPA Magazine / June 2019

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Rehabilitation Nursing Documentation

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

Patients, caregivers and other providers have always valued the rehabilitation nurse. In years past, I have worked with nurses on documentation improvements aimed at helping them document skilled interventions to reflect the unique role that they play in the rehabilitation process. Since the Final Rule of 2010 was published, it seems that the emphasis on rehabilitation nursing has waned because there were no specific requirements written for nursing documentation. I hope this has not sent the wrong message to the field about the importance of the role of the rehabilitation nurse. The nurse is integral to the rehabilitation process and the effectiveness and efficiency of returning the patient to the community setting. Without the intervention and carry-over provided by the rehabilitation nurse, the rehabilitation process would take longer and the durability of outcomes would likely suffer. Rehabilitation nurses play an important role in the care and training of the patient. They provide bedside care for the acute phase of the patient’s illness, they educate and train the patient and caregivers about disease process and signs and symptoms of disease, the carry-over function from the therapy gym to the patient’s room, and they establish and teach maintenance of a bladder and bowel routine to name a few things. Documentation of these efforts is still important as it allows an auditor to see the complexity of the daily care provided in the rehabilitation setting and establishes a mechanism for continuity of care. The admission assessment is where it all starts. The rehabilitation nurse does a head to toe assessment in order to determine what the patient’s problem areas are. From there, the nurse creates a plan of care to address the patient’s deficits, risks for complications and educational needs. Once the plan of care is established, the daily documentation should reflect what was done to achieve the goals noted on the plan of care. A daily assessment is completed on each nursing shift. This alone often does not convey the intervention provided that supports the plan of care. Narrative notes remain the best avenue for indicating bedside care rendered and teaching provided. When reviewing your nursing documentation, look for evidence that the patient requires continued skilled services. Staff should focus on writing progress notes that reflect the need for skilled services during each session or shift and include instances where the provided skilled services resulted in functional progress or improved safety. Clinical notes listing systems or functional areas that were assessed followed by the clinician’s analysis of performance demonstrate that during a particular shift, a service was provided that the rehabilitation nurse was uniquely qualified to perform. For example, during each shift a nurse completes an assessment of the patient’s body systems. Stating that a review of systems was performed and the findings were within normal limits rather than that the patient was simply “resting comfortably in bed”

AMRPA Magazine / June 2019 15

communicates a greater level of skill by the assessor. While both may have occurred during the shift, stating that an assessment was performed and detailing the findings will better demonstrate the need for a rehabilitation nurse during each shift instead of an unskilled assistant to assess patients and ensure that they are resting comfortably in bed. Other kinds of statements that convey skilled services include reporting on adaptations made to the patient’s environment, training in the use of adaptive equipment, use of specialized treatment techniques, adjusting the program as the patient’s needs change, and providing analysis and skilled feedback based on the patient’s performance. Include both quantitative and qualitative statements in the documentation. Rehabilitation nurses must prove through their documentation that the patient’s level of function required the unique skills of a rehabilitation nurse around the clock. Most rehabilitation facility documentation includes a nursing plan of care that reflects medical management support and functional carryover plus an education document. Daily notes are more challenging. Common areas flagged on the nursing care plan are skin integrity, pain management, bowel and bladder elimination, and safety. Here are some examples of statements addressing these areas that could be included in the daily shift notes: Checked patient every two hours for position of hemiparetic arm. Repositioned arm each time because patient is neglecting left arm. Patient was unable to participate in therapy sessions this morning due to extreme pain. Continuing to monitor pain levels to achieve control that will allow participation in this afternoon’s program. Changed bladder medication dosage resulted in reduced bladder leakage. Patient did not have any accidents this shift, which is a significant improvement from yesterday when the patient experienced three bladder accidents in one shift. Due to increased confusion tonight, patient required frequent observation from nursing. He required checking every 30 minutes for safety. Patient required redirection about half of the time.

16 AMRPA Magazine / June 2019

// Rehabilitation nurses must prove through their documentation that the patient’s level of function required the unique skills of a rehabilitation nurse around the clock. Most rehabilitation facility documentation includes a nursing plan of care that reflects medical management support and functional carryover plus As nurses try to tell the patient’s story documentation, these two questions should and how? Do your nursing notes show the intervention or treatment strategies notes show how the patient performed or When rehabilitation nursing documentation of these elements it demonstrates the skilled services, and ensures that there will of care for the patient. Ensuring medical everyone’s job on the rehabilitation team. team doing?

through be asked: Why why you chose utilized? Do your progressed? contains all necessity for be a continuity necessity is How is your

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CMS Releases FY 2020 IRF PPS Proposed Rule

On April 17, 2019, the Centers for Medicare and Medicaid Services (CMS) issued the Fiscal Year (FY) 2020 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) annual proposed rule. The proposed rule was published in the Federal Register on April 24, 2019. Comments are due to CMS by June 17, 2019. Key highlights, which are outlined in greater depth below, include the following:

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

The overall proposed payment adjustment for IRFs is an estimated $195 million increase in FY 2022, or about 2.3 percent over FY 2019 IRF PPS payments. As anticipated, CMS stated that it will proceed to remove the FIMTM Instrument and associated Functional Modifiers from the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) beginning with FY 2020. CMS proposes to use a weighted motor score effective for FY 2020, rather than the unweighted motor score that was finalized in the FY 2019 IRF PPS rule. The rule includes the traditional yearly updates of the IRF market basket, laborrelated share, outlier payments, and other payment factors. Of note, CMS is proposing a change to use the current IPPS wage index to adjust IRF payments, and also solicits comments on use of the IPPS wage index generally.

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

CMS proposes to rebase the IRF market basket by adjusting the categories and corresponding weights used for the market basket. For the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP), CMS proposes to add two Transfer of Health Information measures to meet requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. The rule proposes to add a series of new standardized patient assessment data elements (SPADEs) to the IRF-PAI effective October 1, 2020, and CMS also proposes to expand IRF-PAI data collection to all patients regardless of payer.

Mimi Zhang, AMRPA Director of Payment Innovation, Quality and Research

CMS proposes to amend the definition of “rehabilitation physician” under the IRF coverage regulations to provide additional deference to hospitals

AMRPA Magazine / June 2019 19

These issues and their potential impact are discussed in turn below: PROPOSED REFINEMENTS TO THE CASE-MIX CLASSIFICATION SYSTEM BEGINNING WITH FY 2020 A. Proposed Use of a Weighted Motor Score Beginning with FY 2020 1. Replacement of Previously Finalized Unweighted Motor Score with Weighted Motor Score for FY 2020 & Updated Motor Score Items Currently, the IRF case-mix classification system uses a weighted motor score based on FIMTM data items to assign patients to CMGs. With a weighted motor score, data items (i.e., eating and upper body dressing, etc.) are weighted to reflect their relative contributions to the cost of care. Under the FIM™, 12 items were assessed on a scale of 1-7 (allowing for a score of 12-84), with activities weighted based on cost (by way of example, under the current FIM™ scale, the highest weighted score was bed/chair/wheelchair transfer 1.4, while the lowest weighted score was were bowel, grooming and upper body dressing). In the FY 2019 IRF PPS final rule, CMS said it would use an unweighted motor score derived from the 19 standardized patient assessment data elements (SPADEs) located in the Quality Indicators section of the IRF-PAI. CMS asserted that using an unweighted motor score for the SPADE-based motor score would “facilitate greater understanding among the provider community, as it is less complex.” In the FY 2020 proposed IRF PPS rule, however, CMS states that it considered feedback from stakeholders requesting that CMS “consider applying weights to the motor score,” and accordingly, CMS asked the Research Triangle Institute, International (hereinafter RTI) to explore the “potential of applying unique weights to each of the 19 items in the motor score.” Therefore in this year’s rule, CMS proposes to use a weighted motor score based on the findings of RTI’s analysis. In its work, RTI used regression analysis to determine the impact of each of the proposed motor score items on cost and then weight each item in the index according to its relative impact on cost using FY 2017 and FY 2018 data.1 To calculate weights, RTI assessed the degree of multicollinearity between the SPADEs. Specifically, RTI identified three pairs of items that it determined to be “highly correlated”: Lower Body Dressing and Putting On/Taking Off Footwear Sit to Lying and Lying to Siting on Side of Bed Sit to Stand and Chair/Bed-to-Chair Transfer Weights were calculated for these pairs (using the average of each pair of item scores), and each item was assigned half the calculated weight. For walking, the calculation was based on the item “walk 10 feet,” and the weight was 1

divided equally across all three walking items (walk 10 feet; walk 50 feet with two turns; walk 150 feet). For other motor items, RTI’s model calculated weights individually, rather than as a pair. Overall, with respect to process: RTI calculated weights for the motor items using ordinary least squares (OLS) regression to estimate the relative importance of each motor item in predicting wage-adjusted costs of care; The model included each motor item (or pairs, in the case of the three pairs noted above), as well as age at admission, the communication items sum score (IRF-PAI Section BB), and the BIMS (IRF-PAI Section C); The coefficients for each item were divided by the mean wage-adjusted cost in the sample to determine their relative size (the “initial weights”); The weights were then rescaled to a weighted average of 1 across each of the motor items so the weighted and unweighted motor scores would have the same range. RTI states that it found a high degree of correlation in the weighted and unweighted motor scores (See Figure D-1 in the RTI report), but found that use of the weighted motor score was associated with a small increase the predictive power of the overall model (R-squared 0.3341 unweighted versus 0.3359 weighted; adjusted R-square 0.3338 unweighted versus 0.3355 weighted). In the proposed rule, CMS states RTI’s analysis “suggest[s] that the use of a weighted motor score index slightly improves the ability of the IRF PPS to predict patient costs.” As such, CMS states that it “now believe[s] that a weighted motor score would improve the accuracy of payments to IRFs, and [CMS is] proposing to replace the previously finalized unweighted motor score with a weighted motor score to assign patients to CMGs beginning with FY 2020.” 2. Proposed Motor Score Elements In the FY 2019 IRF PPS final rule, CMS stated that the motor score would be based on 19 motor items. In its updated analysis, RTI considered all self-care and mobility items in Section GG for inclusion in the motor score. RTI specifically excluded the following items from its analysis (as consistent with its approach last year), as RTI found these items are less likely to be attempted on admission due to the patient’s medical condition or safety concerns may prevent assessment: Walking on uneven surfaces Car transfer Steps Pick Up Object Furthermore, based on RTI’s updated analysis, CMS proposes to remove one of the 19 SPADE motor items finalized in the FY 2019 IRF PPS final rule – “GG0170A1 roll left and right.” RTI states that its analysis “identified a high degree of multicollinearity [of GG1070A1] with other SPADEs” and the

RTI International, Analyses to Inform the Use of Standardized Patient Assessment Data Elements in the Inpatient Rehabilitation Facility Prospective Payment System. March 2019.

20 AMRPA Magazine / June 2019

item was “inversely correlated with costs after controlling for each of the other self-care and mobility items.”

One-step curb Bladder continence

GG0170M1

1.4

H0350

1.3

RTI also noted that it used a single motor score, rather than separate self-care and mobility scores, to (1) be consistent within the current IRF PPS and (2) because the analysis are conducted within RICs, rather than conducted in aggregate across diagnoses groups.

Sit to stand

GG0170D1

1.1

Chair/bed-to-chair transfer

GG0170E1

1.1

Lower-body dressing

GG0130G1

1.0

Of note, RTI opted not to use wheelchair mobility items as separate items in the motor score, opting to instead only include walking items to measure mobility. RTI assigned patients who do not walk to the most dependent response category for the walking items to reflect the greater resource use associated with patients who cannot walk. RTI further explained that if the wheelchair mobility item scores were included, then “some wheelchair users would have higher motor scores because they were not completely dependent in wheelchair mobility,” and that using the walking items only to assess mobility ensures that the “motor score reflects increased resource use and need for assistance among patients who do not walk.”

Putting on/taking off footwear

GG0130H1

1.0

Walk 10 feet

GG0170I1

0.8

Walk 50 feet with two turns

GG0170J1

0.8

Walk 150 feet

GG0170K1

0.8

Shower/bathe self

GG0130E1

0.7

Bowel continence

H0400

0.7

Upper-body dressing

GG0130F1

0.5

Oral hygiene

GG0130B1

0.3

Sit to lying

GG0170B1

0.1

Lying to sitting on side of bed

GG0170C1

0.1

The chart below (Table 1) shows the comparison of the weights used for the 12 FIM™ motor score items versus the 18 SPADE-based weighted motor scores included in the FY 2020 proposed rule. The proposed weights for each component of the motor score are averaged through 1 and obtained through the aforementioned RTI regression analysis:

Table 1 FY 2019 Scoring for 12 FIM Motor Items Item Description

Item Number

Weight

Bed, chair, wheelchair transfer

39Ia

2.2

Walk/wheelchair

39La

1.6

Stairs

39Ma

1.6

Toilet transfer

39Ja

1.4

Dressing—lower

39Ea

1.4

Toileting

39Fa

1.2

Bathing

39Ca

0.9

Eating

39Aa

0.6

Bladder

39Ga

0.5

Bowel

39Ha

0.2

Grooming

39Ba

0.2

Dressing—upper

39Da

0.2

Proposed FY 2020 Motor Score Index for 18 SPADEs Item Description

Item Number

Weight

Eating

GG0130A1

2.7

Toileting hygiene

GG0130C1

2.0

Toilet transfer

GG0170F1

1.6

Overall, CMS proposes to determine the motor score by applying each of the weights indicated in Table 1 to the score of each corresponding item, and then summing the weighted scores for each of the 18 items that compose the motor score. B. Proposed Refinements to the CMGs & CMG Relative Weights Beginning in FY 2020 In order to use Quality Indicator data in place of FIMTM data for payment purposes, CMS proposes to revise the IRF PPS casemix classification system and implement new CMGs beginning October 1, 2019 (FY 2020). CMS proposes modifications to its previously published SPADE-based CMGs (issued with the FY 2019 IRF PPS proposed rule), due to its decision in the FY 2019 IRF PPS final rule to use two years of data (FY 2017 and FY 2018) in the analyses used to revise the CMG definitions (see section (a) below). Furthermore, while CMS previously finalized a provision in the FY 2019 IRF PPS to include memory and communication in the function score, it proposes in the FY 2020 IRF PPS to not include cognitive items in the function score at this time (see section (b) below). Under the current IRF PPS case-mix system, a patient is classified into one of 92 CMGs based on the patient’s principal diagnoses or impairment, functional status (as captured on the FIMTM instrument), and for certain CMGs, age. The functional status component is comprised of a weighted FIMTM motor score and an unweighted FIMTM cognitive score. Of note, the FIM™ items assessed a patient’s most-dependent status, whereas the SPADEs assess a patient’s “usual performance” during the assessment period. As described in greater detail below, RTI’s analysis based on FYs 2017-2019 data yielded 97 CMGs. While this reflects an overall increase in CMGs, certain rehabilitation impairment categories

AMRPA Magazine / June 2019 21

Table 2: CART-Based CMGs for RIC 12 (Osteoarthritis) and RIC 16 (Pain Syndrome)

(RICs) – such as RIC 01 Stroke– would face a smaller number of CMGs (by way of example, RIC 01 Stroke specifically would transition from having 10 CMGs in FY 2019 to 7 CMGs in FY2020). A full explanation of the changes to the CMGs is found in section (c), as well as an overview of changes to the average length of stay (LOS) and CMG weights. eveloping the Case-Mix Classification System for D FY 2020 In preparation for the FY 2019 IRF rulemaking, CMS and RTI developed the new case-mix classification system and associated CMGs based on one year of data – FY 2017. For the purposes of updating CMGs/weights for FY 2020 rulemaking, RFI updated and refined its earlier work using both FY 2017 and FY 2018 data.

Consistent with the approach used in the development of the current IRF PPS, RTI used Classification and Regression Tree (CART) analysis to create the new CMGs based on Quality Indicators data collected at patient admission for motor function, cognitive function and age. RTI notes that the analysis used in conjunction with the FY 2019 IRF PPS rulemaking was refined for the purposes of the FY 2020 proposed rule analysis to incorporate a weighted motor function, as described in earlier sections. The dependent variable in the CART regression was IRF stay costs. CART models were run separately for each RIC, using the same methodology used to develop the initial IRF payment system (allowing for diagnosis-specific splits based on weighted motor score, etc.) For the FY 2020 IRF proposed rule, RTI used a sample of 551,503 IRF stays to generate the set of CMGs using SPADE elements. To develop the proposed revised CMGs, RTI used CART analysis to divide patients into payment groups based on similarities in their clinical characteristics and relative costs. As part of this analysis, RTI imposed constraints on the payment group divisions (for example, on the minimum number of cases that could be in the resulting payment groups and the minimum dollar payment amount differences between groups) to identify the optimal set of payment groups. For a more detailed discussion of the analysis used to revise the CMGs for FY 2020, please see the March 2019 technical report entitled, “Analyses to Inform the Use of Standardized Patient Assessment Data Elements in the Inpatient Rehabilitation Facility Prospective Payment System” available at https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/ Research.html. 2. Changes to Cognitive Measurement Component of CMGs In the FY 2019 IRF PPS final rule, CMS finalized the construction of a motor score, a memory score and a communication score to be considered for use in its ongoing analysis to revise the CMG. In developing the proposed CMGs using both FY 2017 and FY 2018 data, however, cognitive status as reflected through the communication

22 AMRPA Magazine / June 2019

score emerged as a potential split point for CMGs in RICs 12 (osteoarthritis) and 16 (pain syndrome). CMS states that, consistent with its discussion in the FY 2019 IRF PPS final rule, it believes the inclusion of the communication score in these CMG definitions would result in lower payments for patients with higher cognitive deficits. To avoid this perceived outcome, CMS proposes to combine the CMGs within these RICs. The tables below demonstrate the CART-based CMGs for RIC 12 and RIC 16 with the communication score. The full table of proposed CMGs at the end of this section shows the proposed CMGs for RIC 12 and 16, which do not include communication scores (there would be 4 total CMGs for RIC 12 and 4 total CMGs for RIC 16). RTI notes that “even without the explicit use of cognitive items in the CMG definitions, the function rating scale for the SPADEs may capture aspects of cognitive status.” CMS notes that while the memory score did not emerge as a potential split point in the CART analysis and the communication score was not ultimately selected as a determinant for the proposed CMGs, both scores were considered as possible elements in developing the proposed CMGs. Ultimately, the proposed FY 2020 CMGs do not include cognitive function status.

3. Updated CMGs, CMG Weights & Average Length of Stay

For FY 2020, CMS proposes to use the FY 2017 and FY 2018 IRF claims and FY 2017 IRF cost report data to update the CMG relative weights and average length of stay values. With respect to average LOS, this metric is used to determine when an IRF discharge meets the definition of a short-stay transfer, which consequently results in a per diem case level adjustment. In calculating the CMG relative weights, CMS proposes to continue to use a hospital-specific relative value method to estimate operating (routine and ancillary services) and capital costs of IRFs. Consistent with the methodology that CMS has used to update the IRF classification system in each instance in the past, CMS proposes to update the relative weights associated with the revised CMGs for FY 2020 in a budget neutral manner by applying a budget neutrality factor to the standard payment amount.

Please see the Table 3 in the rule for the full table of new proposed FY 2929 CMGs, the functional status scores and age that will be used to determine CMG placement, proposed relative weights and average length of stay values. CMS believes the following would be the most significant technical differences between the current CMGs and the proposed revised CMGs: There would be five more CMGs (97 instead of 92 currently). A patient’s age would affect assignment for CMGs in RICs 1, 3, 4, 12, 13, 16, 18, 19 and 21, whereas it currently affects assignment for CMGs in RICs 1, 4 and 8. 4 RICs would have fewer CMGs and 10 RICs would have more CMGs, as follows: There would be fewer CMGs in the following RICs:

FY 2019 CMGs

Proposed number of FY 2020 CMGs

RIC 1 – Stroke

RIC 2 – Traumatic brain injury (BI)

RIC 5 – Non-traumatic spinal cord injury (SCI)

RIC 8 – Replacement of lower extremity joint

There would be more CMGs in the following RICs:

FY 2019 CMGs

Proposed number of FY 2020 CMGs

RIC 3 – Non-traumatic BI

RIC 4 – Traumatic SCI

RIC 10 – Amputation, lower extremity

RIC 11 – Amputation

RIC 12 – Osteoarthritis

RIC 13 – Rheumatoid, other arthritis

RIC 16 – Pain Syndrome

RIC 18 – Major multiple trauma, with BI or SCI

RIC 19 –Guillain-Barre

RIC 21 – Burns

4. Provider Impact Analysis of the FY 2020 CMGs and Weights CMS proposes to implement the new CMGs in a budgetneutral manner relative to current spending, and hence the overall 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. Because CMS proposes to implement the new CMGs in a budget-neutral manner, the new CMGs would not affect the total estimated aggregate payment amount to IRFs. However, RTI noted several payment redistributions at the provider level:

IRFs in rural areas would experience a 1.8 percent increase in average payment; Urban IRFs would experience a 0.1 percent decrease; Freestanding IRFs would see a payment decrease (2.2 percent decrease for urban freestanding IRFs, and 3.6 percent decrease for rural freestanding hospitals); and IRF units would see payment increases (2.5 percent increase for urban units, and 2.9 percent increase for rural units). The estimates do not account for possible behavioral changes by IRFs. Additional information can be found in the provider-specific impact files. PROPOSAL TO CLARIFY THE DEFINITION OF A REHABILITATION PHYSICIAN CMS proposes to alter its regulations to clarify the definition of a rehabilitation physician under its coverage rules. CMS proposes to state in the regulations that the definition of a rehabilitation physician is “a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation.” CMS says it is making this change to clarify that the IRF is in the best position to determine whether a physician is appropriately qualified, and it is important for IRFs and Medicare contractors to be on the same page about the rehabilitation physician requirement. Currently, CMS regulations dictate that for an IRF stay to be considered reasonable and necessary, a rehabilitation physician must conduct face-to-face visits with the patient at least three days per week, concur with the findings and results of a preadmission screening (PAS), complete a post-admission physician evaluation (PAPE), develop an individualized overall plan of care (IPOC), and lead a weekly interdisciplinary team meeting.2 The definition of the rehabilitation physician for these purposes currently is “a licensed physician with specialized training and experience in inpatient rehabilitation.”3 However, there is no further clarification in the regulations as to what training or experience is needed, or which entity is responsible for making this determination. The proposal would amend the coverage regulation by removing the part of the sentence at 42 C.F.R. § 412.622(a)(3)(iv) that currently states the definition of the rehabilitation physician is a licensed physician with specialized training and experience in inpatient rehabilitation. It would also make small changes to other portions of the regulations that reference to that sentence. In its place, CMS would add a subparagraph to the very end of the coverage regulations, at what would be 42 C.F.R. § 412.622(c) entitled Definitions, which would read: “(c) Definitions. As used in this section— Rehabilitation physician means a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation.”

42 C.F.R. § 412.622

42 C.F.R. § 412.622(a)(3)(iv) (The entire sentence reads: “Requires physician supervision by a rehabilitation physician, defined as a licensed physician with specialized

AMRPA Magazine / June 2019 23

FINANCE AND LABOR PAYMENT CHANGES A. Proposed Updates to the Wage Index: Use of Concurrent IPPS Wage Index, Solicitation of Comments on Use of IPPS Wage Index, Proposed Adjustments in IPPS Wage Index to Address Disparities 1. Proposal in IRF Proposed Rule to Use Concurrent IPPS Wage Index Historically, the IRF PPS has used the previous year’s IPPS wage index to adjust IRF payments geographically. This means that if CMS continued with this policy, IRF payments for FY 2020 would be adjusted using the FY 2019 IPPS wage index. AMRPA has commented to CMS in the past that this disadvantaged IRFs for several reasons, including that IRFs must compete with other health care settings for the same personnel, most of which use an up-to-date wage index factor. CMS states that due to concerns such as these, as well as the fact that it is seeking to move towards a unified PAC payment system, it is proposing to begin using the current year’s IPPS wage index to adjust IRF payments. CMS proposes to begin using the current year’s wage index immediately in FY 2020. As it usually does, CMS proposes to make any wage index changes budget neutral, so a wage index budget neutrality factor is applied to the updated standard conversion factor to account for these changes.

Page 17,278 of the proposed rule contains a table breaking down the distributional effects of this proposed change by units versus freestanding, urban versus rural, and several other IRF characteristics. CMS also includes a wage index file as part of its proposed rule release that contains a provider specific analysis of the proposed wage index policies. olicitation of Comments on Use of IPPS Wage S Index in IRF PPS Rule In addition to proposing to begin using the current year’s IPPS wage index, CMS included a separate section seeking comment on the use of the IPPS wage index, regardless of which year is used. CMS has said it has heard complaints about using a different setting’s wage index to adjust IRF payments. Therefore, it seeks potential proposals to improve how CMS geographically adjusts IRF payments.

3. Proposal to Address Disparities in Wage Index Levels in IPPS Proposed Rule In the IPPS proposed rule, CMS seeks to address the issue of the large disparity in wage index adjustments among hospitals located in different areas. While these proposals will not apply to the wage indexes used by IRFs, if finalized this would create a disparity between the wage index applied to IRFs and IPPS hospitals in some markets.

In the proposed rule, CMS describes how some hospitals receive very low wage index adjustments compared to their peers, usually because of their status as rural hospitals. Also, due to the fact that hospital cost reports are used to determine wage index values, the gap continues to grow as rural hospitals receive lower payments, need to keep their pay low, and then receive future wage index values that may be even lower due to their inability to raise pay. 24 AMRPA Magazine / June 2019

To address the disparity and pattern, CMS proposes to readjust payments for providers in the top and bottom quarter of the wage index. Specifically, CMS proposes to adjust upwards the wage index of hospitals that fall in the bottom quartile of the wage index. The increase factor CMS proposes would be equal to half of the difference between the hospital’s unadjusted wage index and the lower quartile threshold. To make this proposal budget neutral, CMS proposed to reduce the wage index of hospitals in the upper quartile of providers. To do this, CMS proposes to reduce payments to upper quartile providers by a factor of 3.4 percent of the difference between a hospital’s unadjusted wage index and the upper quartile threshold. CMS proposes to make these adjustments for at least four years to allow time for low index hospitals to boost pay, beginning in FY 2020. CMS also points out the current wage index system can be manipulated through the use of the rural floor. The rural floor policy states that urban hospitals cannot be paid less than its rural counterparts in their state. Therefore, through the ability of acute-care hospitals to be reclassified from urban to rural, a hospital with a high wage index could be reclassified to rural and raise the minimum wage index for all urban providers in the state. To address concerns about the wage index being manipulated, CMS proposes a change to how the rural floor will be calculated. CMS proposes to remove any urban hospitals that have been reclassified as rural from the calculation of the rural floor. Providers would retain the ability to be reclassified, but would simply not be taken into account when calculating the rural floor. CMS proposes to make this a permanent policy beginning in FY 2020. CMS also proposes a two year transition year for hospitals that will have its wage index lowered as a result of this policy. CMS proposes that in FY 2020, no hospital will have its wage index lowered to more than 95 percent of its FY 2019 wage index. This will allow for any changes to take place over two years, rather than one. B. Proposed Rebasing and Revisions to IRF Market Basket Beginning in FY 2016, CMS began using an IRF-specific market basket for the IRF PPS. This market basket used FY 2012 costs as a base year for weighting different cost categories within the market basket. CMS now proposes to update the market basket by rebasing it based on FY 2016 Medicare cost reports. This rebasing involves recalculating the weights given to each cost category as well as determining which price proxy to use for each cost category in the market basket. 1. Background CMS creates its IRF PPS market basket in three steps. First, CMS estimates costs for the base period, separates these costs into categories, and each category is assigned a weight based on the proportion of total costs it makes up. Next, each cost category is matched to an appropriate price or wage variable, referred to as a price proxy. Finally, the cost weight for each cost category is multiplied by the established price proxy. The sum of the results of the cost weight multiplied by the price proxy yields the market basket index. This type of market basket is a fixed-weight market basket, so the cost weights do not change from year to year.

Only in years when CMS rebases the market basket, such as this year, will the cost weights change. The changes that occur in non-rebasing years are due to forecasted changes in the price proxy used for each category. CMS proposes to use cost reports from IRFs from FY 2016 to determine the total costs, and ultimately the weights, for each category. To determine appropriate market basket weights, CMS proposes to exclude reports from providers that had a Medicare average length of stay (LOS) that was more than 15 percent higher or lower than the national average LOS. CMS said it similarly excluded providers that were more than 15 percent higher or lower than the average LOS for its FY 2012 market basket and it resulted in about eight percent of total facilities being excluded from the cost determinations. As CMS did for the 2012-based IRF market basket cost weights, the proposed 2016-based IRF market basket cost weights reflect all Medicare allowable costs â&#x20AC;&#x201C; including routine, ancillary and capital that are eligible for reimbursement through the IRF PPS. CMS proposes to continue to use the seven major cost categories it uses in the current market basket: Wages and Salaries, Employee Benefits, Contract Labor, Pharmaceuticals, Professional Liability Insurance, Capital and Residual costs. In addition, CMS is proposing to add an eighth category: Home Office Contract Labor. To determine the weights for each category, CMS first trims outliers by removing providers that have costs for a category that fall in the top or bottom 5 percent of all providersâ&#x20AC;&#x2122; costs for that category. After removing the outliers, CMS sums the remaining costs for each category and divides by the total allowable costs to determine the cost weight. Currently, the highest weighted categories are Wages and Salaries (47.3%) Employee Benefits (11.2%) and the Residual category (26.1%). For hospital-based units, often times the costs reflected on Medicare cost reports are not clearly attributable to a particular unit of a hospital. In those instances, CMS makes assumptions about how to best attribute a portion of the hospital-wide cost to the IRF unit. Below is a description of how CMS determines the costs for each category based on Medicare cost reports, the weight it proposes to assign the category, as well as the price proxy it chooses to use for each category. The exact lines of the Medicare cost reports that CMS proposes to use to determine costs can be found broken down by category on pages 17,262-17,264 of the proposed rule. 2. Wages and Salary Cost Category For freestanding IRFs, CMS proposes to determine Wage and Salary costs as the sum of routine inpatient salaries, ancillary salaries, and a proportion of overhead salaries that are allowable under Medicare and as reported on cost reports. For IRF units, CMS will also utilize the routine inpatient salaries for the IRF unit. However, since providers are not asked to attribute wages to a specific unit, to determine which percentage of the ancillary and overhead salaries to attribute to the IRF unit, CMS proposes a

methodology using other information found in the Medicare costs reports. The precise methodology and cost report lines CMS proposes to use can be found on page 17,262 of the proposed rule. Based on these calculations, CMS proposes that wages and salaries will be weighted at 47.1 percent, down slightly from the current weight of 47.3 percent. For a price proxy, CMS proposes to continue to use U.S. Bureau of Labor Statistics (BLS) Employment Cost Index (ECI) titled Wages and Salaries for All Civilian Workers in Hospitals. 3. Employee Benefits Cost Category For freestanding IRFs, CMS proposes to use the benefit costs reported on Medicare cost reports. For units, since there is no line in Medicare cost reports that asks providers to indicate employee benefits attributable to a specific unit, CMS will calculate unit costs differently. CMS will use a methodology to find the proportion of the hospitalâ&#x20AC;&#x2122;s cost attributable to the unit. The more specific methodology and cost report lines CMS proposes to use can be found on page 17,263 of the proposed rule. Using these calculations, CMS proposed that employee benefits will be weighted at 11.3 percent, a slight increase from the current weight of 11.2 percent. For a price proxy, CMS proposes to continue to use BLS ECI titled Total Benefits for All Civilian Workers in Hospitals. 4. Contract Labor Cost Category The Contract Labor Cost Category refers to contract costs that are associated with direct patient care services. Other contract labor costs are put in the residual category, except for Home Office Labor Costs. CMS proposes to utilize the information provided on cost reports to determine total contract labor costs for both freestanding IRFs and units. The exact methodology and cost report lines CMS proposes to utilize can be found on page 17,263 of the proposed rule. The proposed weight for contract labor costs is up slightly to 1.0 percent from the 0.8 percent utilized in the current market basket. As it has done in previous years, CMS allocates the contract labor costs between the Wages and Salaries and Employee Benefits Cost Categories before calculating the final market basket. This year, CMS proposes to allocate 81 percent of the Contract Labor cost weight to the Wages and Salaries cost weight and 19 percent to the Employee Benefits cost weight, as it had done in previous years. Also, because this weight is allocated, it does not have a price proxy, and its weight is tied to the Wages and Salaries and Employee Benefits cost category proxies. 5. Pharmaceuticals Cost Category CMS proposes to utilize the directly reported cost report data for freestanding IRFs to determine the Pharmaceutical Cost Category weight. For IRF units, similar to Wages and Salaries and Employee Benefits categories, CMS will use additional information found in the cost reports to determine how much pharmaceutical cost can be attributed to the IRF unit. This methodology is found on page 17,263 of the proposed rule. Using this methodology, CMS proposes a weight of 5.1 percent, which is the same weight used in the current market basket. For a price proxy, CMS proposes

AMRPA Magazine / June 2019 25

to continue to use BLS Producer Price Index (PPI) entitled Pharmaceuticals for Human Use, Prescription. 6. Professional Liability (Malpractice) Insurance Cost Category CMS proposes to utilize premiums, paid losses and selfinsurance costs reported by freestanding IRFs on cost reports to determine Professional Liability Insurance (PLI) costs. For IRF units, CMS proposes to assume that PLI costs for the unit are proportionate to the rest of the hospital. Therefore, it proposes to determine unit-based PLI costs by taking the total facility PLI cost, dividing by total facility costs, and then multiplying by the IRF unit Medicare allowable total costs. The exact Medicare cost report lines CMS proposes to utilize can be found on page 17,263 of the proposed rule. Using this methodology, CMS proposes a slightly lower PLI cost weight of 0.7 percent, compared to the 0.9 percent in the current market basket. For a price proxy, CMS proposes to continue to use the CMS Hospital Professional Liability Index to measure changes in PLI premiums.

ome Office/Related Organization Contract Labor H Cost Category As previously mentioned, CMS proposes to make Home office/Related Organization Contract Labor Costs its own major market-basket category for this updated market basket. These costs were previously included in the residual category. In the 2012-based market basket, CMS estimated these costs by using expense data published by the Bureau of Economic Analysis (BEA). For this update, CMS proposes to use Medicare cost report data to calculate the costs. For both freestanding hospitals and units, CMS proposes to determine the weight of these costs by dividing reported home office contract labor costs by the reported total facility costs. CMS says that for units this would mean assuming that each unit in the facility utilizes these resources of the home offices equally. Using this methodology, described in more detail in the proposed rule, CMS proposes to weight Home office/Related Organization Contract Labor Costs at 3.7 percent of the market basket.

In addition, CMS proposes to continue to trim outliers for the Home Office Contract Labor cost weight in a slightly different manner than the proposed trimming methodology for the other cost categories. CMS proposes to trim only the top 1 percent of outlier providers, and not trim from the low end of providers, including to continue to include all providers that reported zero home office costs in the weighting calculation, since some facilities do not have home offices. For assigning price proxy, CMS proposes to continue dividing the weight for this category and group it with similar categories that use an appropriate proxy for these costs. Specifically, CMS proposes to group this category with the Professional Fees â&#x20AC;&#x201C; labor and non-labor Related Categories. CMS is proposing to continue to use the same proxies for these categories as it had used in previous years. Therefore, it is unclear why CMS decided to make the home office cost reports its own major category if it was just going to be assigned to the same proxies that had been used previously. 26 AMRPA Magazine / June 2019

8. Capital Cost Category For freestanding IRFs, CMS would determine the Capital Cost Category weight by dividing the total allowable capital costs reported by the total allowable costs. For units, CMS will calculate capital costs based the reported IRF unit capital costs plus the portion of ancillary capital costs attributable to the unit. CMS offers a detailed methodology of how it will attribute the ancillary capital costs to the units on page 17,264 of the proposed rule. Using this methodology, CMS proposes that capital costs will be weighted at 9 percent, up slightly from the current weight of 8.6 percent. CMS further proposes to divide capital costs into the following subcategories: depreciation, interest, lease and other capitalrelated costs. CMS is also proposing to break down the interest category into government/nonprofit and for-profit categories, as well as to redistribute the lease category amongst the other categories. The below chart displays how CMS proposes to break down and redistribute the capital cost subcategories. Table 7: Capital Cost Share Composition for the Proposed 2016-Based IRF Market Basket

CMS proposes to use the same price proxies it used for these subcategories in the current market basket. In addition, CMS proposes to continue to vintage weight the capital price proxies for depreciation and interest to capture the long-term consumption of capital. Vintage weighting refers to the CMS policy to assign the cost of the capital across several years to reflect that capital is not consumed in the same year it is purchased. 9. Residual Cost Category CMS proposes to put seventeen additional cost categories into the Residual Cost Category. These categories are: (1) Electricity, (2) Fuel, Oil and Gasoline (3) Food: Direct Purchases, (4) Food: Contract Services, (5) Chemicals, (6) Medical Instruments, (7) Rubber & Plastics, (8) Paper and Printing Products, (9) Miscellaneous Products, (10) Professional Fees: Labor-related, (11) Administrative and Facilities Support Services, (12) Installation, Maintenance and Repair, (13) All Other Labor-related Services, (14) Professional Fees: Nonlabor-related, (15) Financial Services, (16) Telephone Services, and (17) All Other Nonlabor-related Services.

Differing from the 2012-based market basket, there is no Home Office Contract Labor Cost included since CMS has proposed to make that its own major category. CMS also combined the Water and Sewage Costs into the Electricity Cost sub-weight Category for this proposed market basket. The price proxies CMS is proposing to use for these sub-categories can be found beginning on page 17,269 of the proposed rule. Of note, CMS is proposing a change in its methodology for determining the Fuel, Oil and Gasoline price proxy as well as the Medical Instruments subcategory. For the Fuel, Oil and Gasoline price proxy, CMS will use a blend of 90 percent petroleum price proxy and 10 percent natural gas proxy, as opposed to the 70/30 split it used for the 2012 market basket. For the Medical Instrument category, CMS will adjust the price proxy split to 57 percent Surgical and Medical Instruments and 43 percent Medical and Surgical Appliances and Supplies. In the 2012 market basket CMS used a 50/50 split of the price proxies for this category. Finally, CMS also proposes to use a different PPI to determine the costs associated with the Chemical subcategory. CMS proposes to use the same price proxy for all other subcategories.

Table 8: Proposed 2016-bases IRF Market Basket Cost Weights Compared to 2012-bases IRF Market Basket Cost Weithts

10. Final Proposed Market Basket Weights and Proxies The chart below breaks down the major cost category weights, as well as how these weights compare to the weights in the current market basket.

inally, the chart below breaks down the proposed price proxy F for each of the price proxy categories, as well as the proposed weight.

Some categories or subcategories use the same price proxy as another category or subcategory. Therefore, CMS groups them together by the price proxy used. The chart below shows the proposed price proxy categories and how these categories compare to the weights used in the current market basket.

AMRPA Magazine / June 2019 27

Table 13: Proposed FY 2020 IRF Labor-Related Share and FY 2019 IRF Labor-Related Share

C. Proposed Labor-Related Share for FY 2020 The proposed labor related share of IRH/U’s payments for FY 2019 is 72.6 percent, a notable increase from the 70.5 percent used in FY 2019. Despite tweaks to the IRF market basket, CMS continues to define the labor-related share as the sum of the relative importance of the cost categories of Wages and Salaries, Employee Benefits, Professional Fees: Labor- Related, Administrative and Facilities Support Services, Installation, Maintenance and Repair Services, All Other: Labor-Related Services, and a portion of the Capital-Related costs. This laborrelated share was calculated using the proposed updated 2016 market basket. Table 13, displayed above, breaks down the proposed changes in the subcategory weights that make up the labor-related share. D. Proposed Standard Payment Conversion Factor and Payment Rates for FY 2020, Including Market Basket Update and Productivity Adjustment The proposed standard payment conversion factor for FY 2019 is $16,573, an increase factor of approximately 3 percent from the FY 2019 standard payment rate conversion factor of $16,021. This increased amount is the result of a 3 percent rehabilitationspecific market basket update, which is reduced by a mandated 0.5 percentage productivity adjustment, and then further adjusted slightly by a small budget neutrality factor for changes to the CMGs and the wage-index and labor-related share. MS reached the proposed 3 percent market basket update C based on a forecast of growth in the price indexes used in the new proposed market basket. The agency says this estimate was forecasted by IHS Global Inc. (“IGI”), which CMS contracted to perform the forecast. CMS says IGI's forecast used historical data through the fourth quarter of 2018. Additionally, as it usually does, CMS is also proposing that if more recent data are subsequently available between now and when the final rule is released, it would use such data to determine an updated FY 2020 market basket update in the final rule. CMS notes in this portion of the rule that the old 2012 market basket and new updated 2016 market basket have similar forecasted growth over the next 4 years. To determine the productivity adjustment, CMS says statute requires this adjustment to be equal to the 10-year moving 28 AMRPA Magazine / June 2019

average of changes in annual economy-wide private nonfarm business multifactor productivity (MFP). The Bureau of Labor Statistics (BLS) publishes the official measure MFP, and CMS used BLS measure and IGI’s forecast to estimate the MFP at 0.5 percent for FY 2020. Table 15, displayed below, provides a breakdown of the adjustments used to reach the proposed increase in the Standard Payment Conversion Factor for FY 2020. Table 16 beginning on page 17,281 in the proposed rule provides the unadjusted payment rates for all FY 2020 CMGs after applying the proposed updated standard payment conversion factor and proposed updated CMG relative weights.

Table 15—Calculations to Determine the Proposed FY 2020 Standard Payment Conversion Factor Explanation for adjustment

Calculations

Standard Payment Conversion Factor for FY 2019

$16,021

Market Basket Increase Factor for FY 2020 (3 percent), reduced by 0.5 percentage point for the productivity adjustment as required by section 1886(j)(3)(C)(ii)(I) of the Act

x 1.025

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

x 1.0076

Budget Neutrality Factor for the Revisions to the CMG Relative Weights

x 1.0016

Proposed FY 2020 Standard Payment Conversion Factor

= $16,573

E. Continued Use of FY 2014 IRF PPS Facility-Level Adjustment Factors For FY 2020, CMS proposes to continue to hold the facility-level adjustment factors at the same levels it has held them at since FY 2014. These levels include: a LIP factor of 0.3177, a rural adjustment of 14.9 percent, and a teaching adjustment factor of 1.0163.

F. Proposed Update to Payments for High-Cost Outliers and Cost-to-Charge Ratio Ceiling And Urban/Rural Averages For FY 2020 As it does most every year, CMS proposes to update the outlier threshold amount based on what the threshold would need to be for outlier payments to account for 3 percent of total payments. The agency proposes to raise the threshold from $9,402 to $9,935 for FY 2020. At the current threshold, CMS estimates show that outlier payments would be 3.2 percent of total payments for FY 2020. CMS uses FY 2018 claims data to arrive at these estimates. Further, CMS is also proposing a national cost-to-charge (CCR) ceiling of 1.31 for FY 2020, which is the same as FY 2019. CMS arrives at this figure by calculating a CCR that is three standard deviations above the mean CCR nationally. CMS further proposes a national average CCR of 0.500 for rural IRFs and 0.406 for urban IRFs. These rural and urban averages are used as a stand-in when data is not available for the IRF or the IRF has a CCR in excess of the national ceiling. As it usually does, CMS says it will update the outlier thresholds, national CCR threshold, and CCR urban and rural averages in the final rule if more recent data becomes available. CMS estimates this proposal will decrease estimated overall payments to IRFs by about 0.2 percent or $15 million. IRF QUALITY REPORTING PROGRAM PROVISIONS OF THE FY 2020 IRF PPS PROPOSED RULE In this rule, CMS continues to implement quality and data reporting requirements pursuant to the Improving Medicare PostAcute Care Transformation (IMPACT) Act, including adding two Transfer of Health Information quality measures and a series of new standardized patient assessment data elements (SPADEs) to the IRF Patient Assessment Instrument (IRF-PAI) effective October 1, 2020. CMS has published a mockup of the proposed new or modified IRF QRP items effective October 1, 2020, and a change table showing the differences between IRF-PAI v. 3.0 (effective October 1, 2019) and IRF-PAI v. 4.0 (effective October 1, 2020) (link to change table). CMS also proposes to expand IRF-PAI data collection to all patients regardless of payer.

route of transmission of the reconciled medication list (this information does not factor into the quality measure calculation). The measures are not risk-adjusted or stratified. CMS proposes to start collecting the measure via the IRF-PAI for discharges beginning on or after October 1, 2020. Providers’ compliance with measure reporting will be taken into account for the purposes of determining their FY 2022 IRF QRP payment update and beyond. With regard to reporting burden, CMS estimates that the new measures combined will add 0.9 minutes in clinical staff time per patient stay to report the data. The measures, developed under the intent of the IMPACT Act, have been developed for the IRF, LTCH, SNF and HHA settings, and are also proposed for the SNF QRP and LTCH QRP this year. For more information, please see the IRF QRP specification report CMS published with the rule.4

A. IRF QRP Quality Measure Proposals Beginning With the FY 2022 IRF QRP 1. Proposed Transfer of Health Information Measures Beginning October 2020 CMS proposes to adopt to two new measures to the IRF QRP with data collection to start with discharges beginning October 1, 2020 (FY 2021). Transfer of Health Information is a required domain of the IMPACT Act, and CMS has been developing these measures since 2016. These are processbased measures that assess whether or not a “current reconciled medication list” is given to either the subsequent provider or to the patient/family/caregiver when the patient is discharged or transferred from his or her current PAC setting.

In the specification report, CMS provider a general overview of what could be included in a reconciled medication list. Notably, CMS stresses that this information is for guidance purposes only and is not a requirement for information that must be included in a PAC provider’s reconciled medication list in order to meet the Transfer of Health Information measures’ reporting requirements. CMS also states its guidance is not exhaustive of all information that could be transferred. Please refer to the specification report for more details on CMS’ guidance.

The measures are calculated by one standard data element that asks at the time of discharge did the facility provide the patient’s current reconciled medication list to the subsequent care setting, or to the patient/family/ caregiver. It also includes one data element that asks the

CMS proposes to add items A2121, A2122 and A2123, shown here, to the IRF-PAI to collect data for the calculating the Transfer of Health Information measure. Items A2121 and A2122 assess whether a current reconciled medication list was provided to a subsequent facility or the patient/family/caregiver,

TI International and RAND Corporation, Proposed Specifications for IRF QRP Quality Measures and Standardized Patient Assessment Data Elements (SPADEs), R April 2019.training and experience in inpatient rehabilitation.”).

AMRPA Magazine / June 2019 29

CMS on these SPADEs in multiple comment opportunities. The SPADES were also were included in the IMPACT Act National Beta Test that took place in the summer of 2018.

respectively. Item A2123 assess the route of transmission (electronic, verbal, paper-based, or other); this item does not factor into a provider’s performance on the measure. 2. Proposed Modification to Discharge to Community Measure CMS proposes to modify the Discharge to Community (DTC) – Post Acute Care measure to exclude baseline nursing facility (NF) residents from the measures beginning with the FY 2020 IRF QRP. Specifically, CMS proposes to exclude from the measure calculation patients who had a long-term NF stay in the 180 days preceding their hospitalization and IRF stay, with no intervening community discharge between the long-term NF stay and qualifying hospitalization for measure inclusion (i.e., baseline NF residents). The data will be sourced from the Minimum Data Set (MDS). Presence of an OBRA-only assessment (not a SNF PPS assessment) with no intervening community discharge between the OBRA assessment and acute care admission date flags the index IRF stay as baseline NF resident. CMS has adopted four DTC measures for the IRF, LTCH, SNF and HH settings which are “conceptualized uniformly” across settings. CMS is proposing to also exclude baseline NF residents for SNFs and LTCHs in the FY 2020 SNF PPS and LTCH PPS rules this year.

CMS notes that IRF performance improves slightly when baseline NF residents are excluded from the measure calculation. Based on CY 2015-2016 data, the national observed patient-level DTC rate was 64.52 percent with the exclusion, compared to 64.41 when baseline NF residents were included. Facility-level observed discharges to community ranged from approximately 15 percent to 100 percent. Baseline NF residents represented 0.3 percent of the measure population in 2015-2016. CMS is proposing to this measure modification based on stakeholder recommendations, including AMRPA’s. In the FY 2018 IRF PPS proposed rule, CMS sought comment on excluding baseline NF residents from the DTC measure. In response, AMRPA supported the modification and also suggested that CMS consider ways to address NF residents’ needs in quality reporting programs and not wholly exclude them from nursing facilities’ accountability. AMRPA has recommended such a change since the DTC measure was first adopted. B. Proposed Standard Patient Assessment Data Reporting Beginning October 2020 (FY 2021) Pursuant to the IMPACT Act, CMS is required to develop and collect standardized patient assessment data in PAC settings. In this rule, CMS proposes to adopt “many of” the standardized patient assessment data elements (SPADEs) it had previously proposed in the FY 2018 IRF PPS rulemaking. CMS also proposes to use its authority granted under the IMPACT Act to collect social determinants of health (SDOH) information as standardized patient assessment data. CMS believes collecting SDOH data will help inform providers’ understanding of individual patient risk factors and treatment preferences, facilitate coordinated care and care planning, and improve patient outcomes. With the exception of the SDOH items, AMRPA has previously provided input to 30 AMRPA Magazine / June 2019

1. Proposed Assessment Items on IRF-PAI Version 4.0 Almost all of the proposed SPADEs would entail adding new reporting items to the IRF-PAI. In total, CMS proposes to formally adopt the following items as SPADEs based on the requisite IMPACT Act domain, and add any corresponding assessment items to the IRF-PAI. Almost all of the items are proposed for data collection at patient admission and discharge. CMS estimates that reporting the proposed SPADEs will add 7.8 minutes on admission and 11.1 minutes on discharge for a total of 18.9 minutes additional clinical staff time on average per patient.

Cognitive Function and Mental Status SPADEs BIMS: Since the BIMS is already on the IRF-PAI, CMS proposes to formally adopt it as a SPADE. Confusion Assessment Method (CAM): The “short” CAM seeks to assess overall cognitive impairment and distinguish delirium and reversible confusion from other types of impairments. Patient Health Questionnaire-2 to 9 (PHQ-2 to 9): The PHQ seeks to determine a patient’s mood, and particularly whether or not they are depressed or have been. It involves the two versions, and the PHQ-2 is considered a gateway item for the longer PHQ-9.

Special Services Treatments and Interventions (SSTI) SPADEs Cancer Treatment - Chemotherapy (IV, Oral, Other) Cancer Treatment – Radiation Respiratory Treatment – Oxygen Therapy (Intermittent, Continuous, High-concentration Oxygen Delivery System) Respiratory Treatment – Suctioning (Scheduled, As needed) Respiratory Treatment – Tracheostomy Care Respiratory Treatment – Non-invasive Mechanical Ventilator (BiPAP, CPAP) Respiratory Treatment – Invasive Mechanical Ventilator Intravenous Medications (Antibiotics, Anticoagulants, Vasoactive Medications, Other) Transfusions Dialysis (Hemodialysis, Peritoneal dialysis) Intravenous (IV) Access (Peripheral IV, Midline, Central line) Nutritional Approach – Parenteral/IV Feeding Nutritional Approach – Feeding Tube Nutritional Approach – Mechanically Altered Diet Nutritional Approach – Therapeutic Diet High-Risk Drug Classes – Use and Indication. Specifically, CMS proposes one High-Risk Drug Class data element with six sub-element response options that indicate whether or not a patient is taking any medications within six drug classes: Anticoagulants, Antiplatelets, Hypoglycemics (including insulin), Opioids, Antipsychotics, and Antibiotics.

Medical Condition and Comorbidity Data SPADEs

Proposed SPADE and IMPACT Act Domain

Pain Interference. The proposed item asks patients of Pain Effect on Sleep, Pain Interference with Therapy Activities, and Pain Interference with Day-to-Day Activities over the previous five days.

Impairments SPADEs Hearing Vision

IRF Time to Complete, per Assessment (minutes)1

Cognitive Function and Mental Status: Brief Interview of Mental Status (BIMS)

1.8

Cognitive Function and Mental Status: Confusion Assessment Method (CAM)

1.3

Cognitive Function and Mental Status: PHQ-2 or PHQ-9

1.5 to 3.7 minutes

CMS proposes to require reporting Hearing and Vision items at admission only.

SSTI: Cancer Treatment - Chemotherapy (IV, Oral, Other)

0.25

SSTI: Cancer Treatment - Radiation

0.25

Social Determinants of Health: New Proposed SPADEs Category In this rule, CMS proposes to collect and access data about social determinants of health (SDOH) in order to perform responsibilities of the Secretary of the Department of Health and Human Services, pursuant to the IMPACT Act to assess appropriate adjustments to quality, resource use, and other measures, and to assess and implement appropriate adjustments to Medicare payments based on patient socioeconomic/demographic factors. CMS proposes to use the IRF-PAI to collect SDOH data by adding the following IRF-PAI elements: Race and Ethnicity Currently, the IRF-PAI includes a combined Race/ Ethnicity data element. CMS proposes to replace this item with two separate data elements, one on Race and one on Ethnicity. CMS proposes these modifications to conform with the 2011 HHS Data Standards. Preferred Language and Interpreter Services CMS proposes to add to the IRF-PAI the Preferred Language and Interpreter Services data elements. These items are currently used in the MDS and Long-Term Care Hospital CARE Data Set (LCDS). Health Literacy CMS proposes to add the Single Item Literacy Screener (SILS) question to the IRF-PAI. Transportation Access CMS proposes to add one item asking whether the lack of transportation prevented a patient from meeting medical and/or non-medical needs. The proposed item is adapted from the Protocol for Responding to and Assessing Patient Assets, Risks and Experiences (PRAPARE) tool. Social Isolation CMS proposes to add one item that assesses often a patient feels lonely or isolated from those around them. The proposed item is adapted from the Accountable Health Communities Screening Tool from the PROMIS Item Bank on Emotional Distress.

SSTI: Respiratory Treatment – Oxygen Therapy (Intermittent, Continuous, High-concentration Oxygen Delivery System)

0.25

SSTI: Respiratory Treatment – Suctioning (Scheduled, As needed)

0.25

SSTI: Respiratory Treatment – Tracheostomy Care

0.25

SSTI: Respiratory Treatment – Non-invasive Mechanical Ventilator (BiPAP, CPAP)

0.25

SSTI: Respiratory Treatment – Invasive Mechanical Ventilator

0.25

SSTI: Intravenous Medications (Antibiotics, Anticoagulants, Vasoactive Medications, Other)

0.25

SSTI: Transfusions

0.25

SSTI: Dialysis (Hemodialysis, Peritoneal dialysis)

0.25

SSTI: Intravenous (IV) Access (Peripheral IV, Midline, Central line)

0.25

SSTI: Nutritional Approach – Parenteral/IV Feeding

0.25

SSTI: Nutritional Approach – Feeding Tube

0.25

SSTI: Nutritional Approach – Mechanically Altered Diet

0.25

SSTI: Nutritional Approach – Therapeutic Diet

0.25

SSTI: High-Risk Drug Classes – Use and Indication.

1.1

Medical Condition and Comorbidity Data: Pain Interference

1.2

Impairment Data: Hearing – Proposed for Admission Reporting Only

0.3

Impairment Data: Vision – Proposed for Admission Reporting Only

0.3

The estimated completion time for each item listed below is based on results from the National IMPACT Act SPADEs Beta Test. AMRPA has commented previously to CMS that Beta Test completion times underestimate how long it will take most IRFs to assess patients on the new items.

TOTAL of the Above

11.25 to 13.45 minutes

Social Determinants of Health: Race -- Proposed for Admission Reporting Only

Unknown

Social Determinants of Health: Ethnicity -- Proposed for Admission Reporting Only

Unknown

Social Determinants of Health: Preferred Language

Unknown

Social Determinants of Health: Interpreter Skills

Unknown

Social Determinants of Health: Health Literacy

Unknown

Social Determinants of Health: Transportation

Unknown

Social Determinants of Health: Social Isolation

Unknown

AMRPA Magazine / June 2019 31

C. Proposed Data Reporting On All-Payer Patients for the IRF QRP Beginning October 2020 CMS proposes to expand the reporting of the IRF-PAI data to include data on all patients, regardless of their payer, beginning discharges on or after October 1, 2020. This proposal would pertain to all information reported on the IRF-PAI, quality measure data and the SPADEs proposed in this rule (and possibly in future rules). The policy would be effective for the IRF QRP reporting compliance beginning with the FY 2022 IRF QRP performance year. CMS also proposes to display the calculation of this data on IRF Compare if the proposal is adopted. While noting that it does “not have access to other payer claims,” CMS also does not specify how it would operationalize this proposal or verify the IRF-PAIs submitted for non-Medicare patients for determining an IRF’s compliance with the IRF QRP reporting requirements. D. Proposed Policies Regarding Public Display of Measure Data for the IRF QRP CMS proposes to begin publicly displaying data for the Drug Regimen Review measure in CY 2020 or as soon as technically feasible. As with other measure information on IRF Compare, the displayed data will based on four rolling quarters and initially use discharges from January 1, 2019, through December 31, 2019. CMS proposes that it would not publicly report measure performance for IRFs for with fewer than 20 cases during any of the four consecutive rolling quarters to ensure statistical reliability. Those IRFs with fewer than 20 eligible cases would be publicly displayed with a footnote that states, “The number of cases/patient stays is too small to publicly report.” E. Proposed Migration to the Internet Quality Improvement and Evaluation System (iQIES) As previously announced, CMS is migrating to a new iQIES which it says will enable real-time upgrades and other features, including allowing more than two users per facility. CMS proposes to designate iQIES as the data submission system for the IRF QRP beginning October 1, 2019, and to update the related regulation text. CMS will notify the public of any future changes to the CMS designated system using subregulatory mechanisms, such as website postings, listserv messaging and webinars.

32 AMRPA Magazine / June 2019

F. Proposed Removal of the List of Compliant IRFs Effective with the FY 2020 payment determination, CMS proposes to discontinue its practice of publishing annually a list of IRFs that were compliant with IRF QRP reporting requirements for the applicable payment determination on the IRF QRP website and update the list on an annual basis. This policy was adopted in the FY 2016 IRF PPS final rule. CMS says it received stakeholder feedback that the list offered “minimal benefit, and although the posting of successful providers was the final step in the applicable payment determination process, it does not provide new information or clarification to the providers regarding their annual payment update status. G. Request for Information: IRF QRP Quality Measures, Measure Concepts and Standardized Patient Assessment Data Elements Under Consideration for Future Years CMS seeks input on the following quality measures, measure concepts and SPADEs it is considering for future use in the IRF QRP. Quality Measures and Measure Concepts Opioid use and frequency Exchange of Electronic Health Information and Interoperability SPADEs Cognitive complexity, such as executive function and memory Dementia Bladder and bowel continence, including appliance use and episodes of incontinence Care preferences, advance care directives and goals of care Caregiver status Veteran status Health disparities and risk factors, including education, sex and gender identity and sexual orientation

Because none of the above items are proposed for adoption in this rule, CMS says it will not be responding to comments submitted specifically on the RFI in the FY 2020 final rule, but will use the input to inform future work.

2019

2019 FALL

Fall Educational Conference Loews Coronado Bay Resort & Expo San Diego, CA | October 14-16, 2019

EDUCATIONAL CONFERENCE & EXPO Loews Coronado Bay Resort San Diego, CA October 14-16, 2019

AMRPA National Leadership Excellence Award AMRPA is now accepting nominations for our annual National Leadership Excellence Award, to be presented at this year’s Fall Educational Conference & Expo in San Diego, CA. The AMRPA National Leadership Excellence Award is an opportunity to offer recognition to individuals who have exemplified outstanding service and made significant contributions to the field of medical rehabilitation. These accomplishments should contribute to the advancement of the medical rehabilitation field as a whole, as opposed to benefiting only an individual’s institution.

Who Qualifies? Nominated persons should exemplify leadership, integrity, vision, dedication, and excellence in at least three of the following areas:     

Transformative Leadership Professional Experience Life-long Service in the Field Advocacy at the State and National Level Mentorship of Future Leaders

 Improved Patient Outcomes/ Quality of Patient Care  Research and Critical Analysis  Education and Advancement of the Field

Nominating parties will be asked to provide examples illustrating such excellence in these categories. Click here for more information.

How Do I Nominate Someone? To nominate a colleague, visit the AMRPA website and complete the Nomination Form. The AMRPA Awards Committee will review all submissions and notify the nominator once the selection is made.

Click here to nominate a colleague!

#AMRPA

Questions about nominations? Contact Julia Scott, AMRPA Member Services Coordinator, at jscott@amrpa.org for assistance.

AMRPA Magazine / June 2019 33

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CMS Proposes Changes for Acute-Care and Long-Term Care Hospitals

On April 23, 2019, the Centers for Medicare and Medicaid Services (CMS) released its fiscal year (FY) 2020 proposed rule for the Inpatient Prospective Payment System (IPPS) and Long-term Care Hospital Prospective Payment System (LTCH PPS). This article summarizes some of the proposals for both facilities found in the proposed rule.

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

Highlights: »»

MS proposes changes to wage C index and technology payments for acute-care hospitals

»»

L TCHs would be subject to full site-neutral payment rates

Inpatient Prospective Payment System Proposals CMS is proposing a number of usual annual adjustments to the base rate, wage index and other payment factors in the IPPS. Due to these changes, CMS projects a 3.7 percent increase in payments to acute-care hospitals that are participating in the Inpatient Quality Reporting (IQR) Program and the Promoting Interoperability program. This increase is the result of an estimated 3.2 percent increase in the market basket used to calculate IPPS rates, as well as wage index adjustments, new technology payments, low-volume payments, and other adjustments to payment factors. In addition to its more typical yearly updates, CMS proposes to make changes to the wage index to account for what it describes as growing disparities in the wage index levels between high- and low-wage areas. To lessen the gap between low- and highwage providers, CMS proposes to adjust upwards the wage index of hospitals that fall in the bottom quartile of the wage index. The increase factor CMS proposes would be equal to half of the difference between the hospital’s unadjusted wage index and the lower quartile threshold. To make this proposal budget neutral, CMS proposes to reduce the wage index of hospitals in the quartile providers by a factor of 3.4 percent of the difference between a hospital’s unadjusted wage index and the upper quartile threshold. CMS proposes to make these adjustments for at least four years to allow time for low index hospitals to boost pay, beginning in FY 2020. In the proposed rule, CMS also noted concerns about the use of reclassification by hospitals to potentially manipulate the rural floor, which is a rule that requires urban hospitals be paid no less than rural hospitals in the same state. CMS says it has concerns that in some instances a high-wage urban hospital will be reclassified to rural, which brings up the rural floor, which in turn brings up the minimum wage index for all hospitals in the state. To rectify this, CMS proposes to no longer factor in reclassified urban hospitals when determining the rural floor for a state. CMS also has proposed additional payments for innovative medical devices. Currently, to receive an add-on payment for new technology, there must be an evidence base for demonstrating substantial clinical improvement. However, the U.S. Food and Drug Administration (FDA) has recently developed more expedited clearance that would lead to a situation where the FDA has approved a device which has not yet technically met CMS’ standards for an add-on payment.

AMRPA Magazine / June 2019 35

Therefore, CMS is proposing that if a new medical device subject to one of the FDA’s expedited programs has received marketing authorization from the FDA, CMS will consider that product new and not substantially similar to an existing technology for purposes of the IPPS, and therefore potentially eligible for an add-on payment. CMS notes that under this proposal the device will still need to meet its cost criteria to receive the add-on payment. In addition, CMS also proposes to raise the maximum add-on payment from 50 percent of the cost of the technology to 65 percent of the cost. The proposed rule also contains a number of yearly updates to the Hospital Value Based Purchased (VBP) Program, as well as changes to the Promoting Interoperability Program. Finally, CMS proposes paying approximately $8.5 billion in uncompensated care payments in FY 2020, an increase of approximately $216 million from FY 2019. Altogether, CMS projects total Medicare spending on inpatient hospital services, including capital, will increase by about $4.7 billion in FY 2020. LTCH PPS and QRP Proposed Changes CMS also proposes a number of changes to the LTCH PPS and Quality Reporting Program (QRP) for FY 2020. The proposed rule continues to implement the site neutral payment policy for discharges that are not excluded from the site neutral rates. This statutory requirement mandates that CMS pay an IPPS equivalent rate to LTCHs unless the case involves a patient admitted directly from an IPPS hospital and had at

least three days in intensive care or the patient required at least 96 hours of respiratory ventilation services in the LTCH. Between FY 2015 and 2019, CMS pays a higher, blended rate for site-neutral cases. However, beginning in FY 2020, CMS proposes to begin paying the regular IPPS equivalent rate for non-excluded cases. Due to this, CMS projects overall payments to LTCHs to increase by approximately 0.9 percent or $37 million. For those cases excluded from the site neutral policy, CMS expects payments to increase by 2.3 percent after accounting for the usual annual updates to the market basket and other payment factors. CMS predicts cases subject to the site neutral payment will decrease by approximately 4.9 percent due to full transition to site neutral payment rates. There are also a number of changes proposed to the LTCH Quality Reporting Program (QRP) for FY 2020. Similar to other settings, LTCHs are subject to a 2 percent reduction for failing to report measures under the QRP. CMS is proposing to adopt two new process measures pertaining to the transfer of health information, as well as update one measure pertaining to the discharge to the community measures which would remove baseline nursing home residents from this measure’s calculation. CMS also proposes a number of new standardized patient assessment data elements (SPADEs) to be collected, as part of the LTCH QRP, on the LTCH patient assessment instrument starting in October 2020. The entire proposed rule can be found in the May 3 edition of the Federal Register.

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EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE AMRPA: Working Together to To Preserve Preserve Access To Medical Rehabilitation AMRPA: Working Together Access to Medical Rehabilitation Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org

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36 AMRPA Magazine / June 2019

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

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

Stay informed! Order your PAC report today. AMRPA Members Receive Reports at Discounted Rates. Visit https://amrpa.org/PAC-Market-Analysis-Reports for more information, or contact Rachel Koresky, AMRPA Operations Manager, at rkoresky@amrpa.org.

38 AMRPA Magazine / June 2019

OIG Recommends Improvements to Lower Deficiencies at Nursing Homes

Highlights: »»

hile the number of nursing home W surveys and deficiencies was on a steady upward trend from 2013 to 2016, 2017 showed signs of improvement.

»»

ore than 50 percent of all of the M documented incidents came from 10 states, including California, Illinois, Indiana, Michigan, Pennsylvania, Ohio and Texas.

»»

ith about 340 deficiency types W identified in the review, the top 10 deficiency types accounted for 40 percent of cases.

A data brief by the Office of the Inspector General (OIG) from the U.S. Department of Health and Human Services painted a mixed picture regarding nursing home deficiencies in states selected for the study. The brief accompanies the OIG report titled, CMS Guidance to State Survey Agencies on Verifying Correction of Deficiencies Needs to be Improved to Help Ensure the Health and Safety of Nursing Home Residents, which was published in February 2019. The analysis revealed that while the numbers of nursing homes surveys and deficiencies was on a steady upward trend from 2013 to 2016, the following year showed signs of improvement in 2017. However, approximately 31 percent of nursing homes had a repeat deficiency, or a deficiency type that was cited at least five times in separate surveys. Further, at least half of these nursing homes experienced an incident of a more serious deficiency, including incidents of substandard quality of care, actual harm and immediate jeopardy to residents.

More than 50 percent of all of the documented incidents came from 10 states, including California, Illinois, Indiana, Michigan, Pennsylvania, Ohio and Texas (see Figure 6).The average number of deficiencies identified per survey was not always higher for states that performed more surveys or identified more deficiencies. For example, Kansas ranked ninth in the number of deficiencies identified and 20th in the number of surveys performed. In addition, Kansas ranked 14th in the average number of deficiencies per survey, while California, the state that identified the most deficiencies and performed the most surveys, ranked 44th in the average number of deficiencies per survey.

AMRPA Magazine / June 2019 39

Data for the analysis was gathered from state standard surveys, as well as investigation of complaints or allegations of noncompliance from nine selected state agencies. The analysis showed that it was common for many of the state agencies analyzed to not collect enough evidence to ensure that the deficiencies have been remedied to comply with Federal participation requirements. According to the OIG, nursing homes may not have been properly implementing systemic changes to ensure that deficiencies do not recur. The data brief did note that the overwhelming majority of deficiencies, 94 percent in total, had less serious ratings.

With about 340 deficiency types identified in the review, the top 10 deficiency types accounted for 40 percent of cases. The most prevalent deficiency type was for the Federal participation requirement related to ensuring that nursing homes are free of accident hazards, provide adequate supervision of residents, and provide adequate assistance devices for residents. Figure 8 shows the top 10 deficiency types, with the highest number of deficiencies identified.

The OIG concluded that it unable to conclude whether the quality of care and the safety of nursing home residents improved during the selected review period. Accordingly, the OIG made the following recommendations in the report and reiterated them in the data brief: 1. CMS should revise and strengthen its guidance to state agencies on verifying nursing homesâ&#x20AC;&#x2122; correction of deficiencies and maintaining documentation to support verification. 2. CMS should consider improving its forms related to the survey and certification process. 3. CMS should work with state agencies to address technical issues with the system for maintaining supporting documentation. CMS concurred with OIGâ&#x20AC;&#x2122;s recommendations and stated it would review its existing policies, systems, and guidance for state agencies to identify key areas to improve education.

40 AMRPA Magazine / June 2019

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Florida Hospital Finds Success with Innovative Discharge Preparation

// Path to Home was developed by a team of physicians, nurses, navigators and others, after they discovered that 78 percent of discharge delays were caused by issues that could be remedied by hospital staff.

A recent profile of Nemours Children's Hospital in Orlando published in Modern Healthcare examined the hospitalâ&#x20AC;&#x2122;s recently implemented Path to Home initiative, which has contributed to a drop in delayed discharge days from 1.04 days to 0.69 days from 2017 to 2018, generating saving of around $425,000 for the hospitalâ&#x20AC;&#x2122;s medicalsurgical unit. Path to Home was developed by a team of physicians, nurses, navigators and others, after they discovered that 78 percent of discharge delays were caused by issues that could be remedied by hospital staff. The Path to Home program aims to identify barriers to a successful discharge within the first few hours of admitting a patient to the hospital, rather than at patient discharge. Issues identified early on in the process can be resolved while the patient is receiving care. Aside from changing the timing of the discharge process, nurses were also instructed to alter the kinds of questions they ask the patients and their families. Nurses were instructed to forgo vague questions and adopt a direct line of questioning designed to elicit more specific responses relevant to the discharge process. Nurses are also expected to follow up on questions every 12 hours to ensure that medical staff and navigators are working with the most up-to-date information possible in preparation for discharge. For more information, see the article Preparing for Discharge Shortly After Admission to Reduce Length of Stay in Modern Healthcare.

AMRPA Magazine / June 2019 43

2019 AMRPA Schedule of Events CONFERENCE DATES 2019 Regional Meeting in Grand Rapids, MI Friday, June 7, 2019: Mary Free Bed Rehabilitation Hospital 2019 Regional Meeting in Jacksonville, FL Friday, June 14, 2019: Brooks Rehabilitation Hospital 2019 Fall Educational Conference & Expo in San Diego Sunday, October 13, 2019: IRF Boot Camp October 14-16, 2019: Fall Conference & Expo AMRPA WEBINARS Thursday, June 13, 2019, Noon ET Road to Recovery: The Intersection between Patient Experience and Patient Education Presented by Patty Jobbitt, MSA, PT Thursday, June 27, 2019, Noom ET Complications of the IRF OIG Audit and Best Practices for Avoiding a Similar Fate Presented by Christina Hughes, JD, MPH and Peter Thomas, JD Thursday, September 12, Noon ET Considerations for Adolescents on Adult Inpatient Rehabilitation Units Presented by Sue Harlow, OTD, OT/L AMRPA MEMBERS ONLY CALLS Wednesday, June 19 at 1:00 p.m. ET Wednesday, August 21 at 1:00 p.m. ET Wednesday, October 23 at 1:00 p.m. ET Wednesday, December 18 at 1:00 p.m. ET eRehabData® WEBINARS: AVAILABLE TO eRehabData® SUBSCRIBERS ONLY Tuesday, June 4: Managing Outcomes with eRehabData

Please visit www.amrpa.org for registration information. 44 AMRPA Magazine / June 2019

CARF to Add Screen for Suicide Risks to Assessment Standards

// Data shows a significant number of individuals who commit suicide were at some point in contact with the behavioral health care system.

With suicides rising steadily over the past decade in the United States, the Commission on Accreditation of Rehabilitation Facilities (CARF) International recently announced the rollout of a new assessment standard that would allow medical professionals to conduct suicide risk screening for all patients over the age of 12. The 2019 standards addition follows a series of previous attempts to evaluate suicide risks in patients in the behavioral health care system. Since publishing their Quality Practice Notice on Suicide Prevention, CARF has developed new program prevention standards every year. The 2019 assessment standard calls for a standardized tool to be utilized while conducting suicide risk screenings, similar to the Columbia Suicide Severity Rating Scale, SAFE-T screener, and ASQ. According to data collected by the Centers for Disease Control (CDC), around 45,000 Americans over the age of 10 committed suicide, and is the 10th leading cause of death in the nation. Forty-nine states experienced an increase in suicide rates of at least 6 percent between 1999 and 2016. Twenty-five states saw suicide rate increase more than 30 percent. Introducing universal screenings within behavioral health care settings can have an outsized impact on suicide rates, since data shows that a significant number of individuals who commit suicide were at some point in contact with the behavioral healthcare system. For more information, see the CARF press release â&#x20AC;&#x153;CARF adds screening for suicide risk to its assessment standards.â&#x20AC;?

Source: https://www.cdc.gov/vitalsigns/suicide/img/vs-0618-Suicide-infographic-1185.png

AMRPA Magazine / June 2019 45

CMS Administrator Outlines Recent Burden Reduction Efforts

// The CMS initiative will revolve around “removing government barriers to innovation” and “harmonizing CMS coverage, coding, and payment processes.”

Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma recently announced a series of initiatives to promote innovation and increase access to innovative treatments. Speaking at the Medical Device Manufacturers Association Annual Meeting, Verma declared that, “the advent of novel medical technologies requires CMS to remove barriers to ensure safe and effective treatments are readily accessible to beneficiaries without delaying patient care. In essence, keeping new technologies and treatments moving from bench to bedside—and into the hands of those who need them most.” The CMS initiative will revolve around “removing government barriers to innovation” and “harmonizing CMS coverage, coding, and payment processes.” The CMS code update would reduce the length of the coding process, and reduce the intervals for code issuance, from annually to semi-annually for devices and quarter-annually for drugs. Verma pointed to the Medicare defined benefits categories as an impediment to innovation, requiring an act of Congress to provide coverage for any such innovations. Verma sought to provide clarity Current Procedural Terminology (CPT) category III code coverage, used for emerging technologies. Medicare contractors will no longer automatically reject covering category III, but instead will be required to use the LCD process for every local coverage decision. CMS also has eliminated the requirement that any new item meet the threshold of a 3% market share. Verma also announced that any rejected applications for code will carry more detailed reasoning as to why they were rejected, allowing for a quicker turnaround time to file a new application. Read the full remarks here.

46 AMRPA Magazine / June 2019

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AMRPA Magazine / June 2019 47

CMS Launches New Payment Models Focused on Primary Care

Highlights: »»

MS Primary Cares Initiative C consists of five model options categorized under two general pathways, Primary Care First and Direct Contracting.

»»

he general PCF payment model T option is designed for primary care practices under Medicare fee-forservice.

»»

he objective of the DC model is to T create a more efficient care delivery system that rewards efficiencies and improved quality of care by facilitating a range of organizations to participate with CMS in testing risk-sharing, value-based arrangements.

»»

MS anticipates releasing a C Request for Application (RFA) in spring 2019 for the first cohort of applicants. Practices and payers will begin participation in the model in January 2020.

U.S. Department of Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma recently announced the launch the CMS Primary Cares Initiative, a new set of voluntary payment models intended to advance Secretary Azar’s value-based healthcare delivery initiatives. “For years, policymakers have talked about building an American health care system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision,” Azar said. “Building on the experience of previous models and ideas of past administrations, these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before. These models can serve as an inflection point for value-based transformation of our health care system, and American patients and providers will be the first ones to benefit.” CMS Primary Cares Initiative consists of five model options categorized under two general pathways, Primary Care First and Direct Contracting: 1. Primary Care First (PCF) 2. Primary Care First – High Need Populations 3. Direct Contracting – Global 4. Direct Contracting – Professional 5. Direct Contracting – Geographic Primary Care First The Primary Care First (PCF) model’s stated goal will be to determine whether the use of performance-based payments will have positive effects on total Medicare expenditures, quality of care and patient outcomes. PCF is a set of voluntary five-year payment options which CMS designed as an extension of the existing Comprehensive Primary Care (CPC+) model. PCF intends to enhance care for patients with complex chronic needs and high need, seriously ill patients, reduce administrative burden, and target financial rewards on improved health outcomes. PCF includes a streamlined payment system that rewards physicians for working with high-need patients and helps re-orient attention away from revenue cycles. Testing with PCF is expected to last for five years, starting in January 2020. The general PCF payment model option is designed for primary care practices under Medicare fee-for-service. CMS says it will also encourage other payers – including Medicare Advantage Plans, commercial health insurers, Medicaid managed care plans, and state Medicaid agencies – to align payment, quality measurement and data sharing with CMS in support of Primary Care First practices. 1. Primary Care First Payment Model Option The PCF payment model option tests whether delivery of advanced primary care can reduce total cost of care and focuses on advanced primary care

48 AMRPA Magazine / June 2019

practices ready to assume financial risk in exchange for reduced administrative burden and performance-based payments. The PCF model option also introduces new, higher payments for practices that care for complex, chronically ill patients. 2. Primary Care First — High-Need Populations Payment Model Option Through a second payment model option, PCF also encourages advanced primary care practices, including practices whose clinicians are enrolled in Medicare and typically provide hospice or palliative care services, to take responsibility for high-need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination. These population groups are referred to under this payment model option as the Seriously Ill Population (SIP).

3. Direct Contracting — Geographic Geographic PBP DCEs will bear risk for 100 percent of shared savings/shared losses on the total cost of care for aligned beneficiaries in a target region. Geographic PBP DCEs will be selected as part of a competitive application process and commit to providing CMS a specified discount amount off of total cost of care for the defined target region. Similar to Professional PBP and Global PBP, Geographic PBP will offer an optional Total Care Capitation payment mechanism. Under this capitation payment, CMS will continue to pay claims for services furnished by providers outside of the DCE, including outside of the target region. Alternatively, Geographic PBP DCEs can assume full financial risk, while having CMS continue to make FFS claims payments to all providers in the target region. In an effort to further refine specific design parameters for Geographic PBP, CMS is seeking additional input from the public through a Request for Information (RFI) on this model.

Direct Contracting The Direct Contracting (DC) payment model options are directed at Medicare fee-for-service (FFS) beneficiaries, and are geared towards organizations such as Accountable Care Organizations (ACOs), Medicare Advantage (MA) plans and Medicaid managed care organizations (MCOs). The objective of the DC model is to create a more efficient care delivery system that rewards efficiencies and improved quality of care by facilitating a range of organizations to participate with CMS in testing risk-sharing, value-based arrangements. With the DC model, CMS seeks to build upon Medicare’s existing Accountable Care Organizations (ACOs), such as the Medicare Shared Savings Program (MSSP) and the Next Generation ACO Model, to incorporate approaches from Medicare Advantage and private sector risk-sharing arrangements.

Timeline CMS anticipates releasing a Request for Application (RFA) in spring 2019 for the first cohort of applicants. Practices and payers will begin participation in the model in January 2020. At this time, CMS anticipates accepting another round of Primary Care First applications during 2020, and that any practices accepted to participate in Primary Care First during 2020 would begin participation in the model in January 2021. The SIP payment model option will also follow this timeline.

Direct Contracting consists of three payment model options for participants to take on risk for the total cost of care (defined as all Part A and Part B services), and earn rewards through PopulationBased Payment (PBP), beneficiary alignment and benefit enhancements:

More information on CMS Primary Care payment model options is available at: https://innovation.cms.gov/initiatives/ primary-care-first-model-options/.

1. Direct Contracting — Professional Professional PBP Direct Contracting Entities (DCEs) will bear risk for 50 percent of shared savings/shared losses on the total cost of care for aligned beneficiaries. Professional PBP DCEs will receive “Primary Care Capitation,” a capitated, risk-adjusted monthly payment for enhanced primary care services equal to 7 percent of the total cost of care for enhanced primary care services. 2. Direct Contracting — Global Global PBP DCEs will bear risk for 100% of shared savings/shared losses on the total cost of care for aligned beneficiaries. Global PBP DCEs will be able to choose between two payment options: Primary Care Capitation, described above, or Total Care Capitation. Total Care Capitation refers to a capitated, risk-adjusted monthly payment for all services provided by DC Participants and Preferred Providers with whom the DCE has an agreement.

For both models, the forthcoming RFAs will include eligibility criteria for interested applicants and further details on the models, such as benefit enhancements and regulatory waivers.

For a fact sheet on the CMS Primary Care First payment model options, visit https://www.cms.gov/newsroom/fact-sheets/ primary-care-first-foster-independence-reward-outcomes. For a fact sheet on the Direct Contracting payment model options, please visit https://www.cms.gov/newsroom/ fact-sheets/direct-contracting. More information on the Direct Contracting model options is at: https://innovation.cms.gov/ initiatives/direct-contracting-model-options/. To view a fact sheet on the CMS Primary Cares Initiative, please visit: https://innovation.cms.gov/Files/x/primary-caresinitiative-onepager.pdf. To review the Direct Contracting—Geographic Request for Information, please visit: https://innovation.cms.gov/Files/x/ dc-geographicpbp-rfi.pdf.

AMRPA Magazine / June 2019 49

CMS, Treasury Department Seeking Comments for Waiver Concepts for ACA State Markets

On May 1, the Centers for Medicare and Medicaid Services (CMS) and the Department of the Treasury issued a request for information (RFI) on the use of Section 1332 waivers to “minimize the economic burdens” of the Patient Protection and Affordable Care Act (ACA) implementation on individual states. Among the issues identified by the Trump administration regarding the ACA state exchanges are the rise of insurance premiums and the departure of available insurers from state and regional markets. The RFI, which was published in the May 3 Federal Register, solicits ideas for programs and waiver concepts that states could consider in developing a 1332 waiver plan. Specifically, the RFI seeks input on how states might use and operationalize recent guidance that was issued by the Department of Health and Human Services (HHS) and the Department of the Treasury in October 2018 on Section 1332 waivers. The October 2018 guidance rescinded guidance issued under the Obama administration, and the Section 1332 waivers give states the flexibility to waive certain requirements of the ACA and to pursue alternative approaches to providing health care coverage. According to a statement published by CMS, the RFI seeks input from stakeholders in order to build “a library of options” of waivers that would help health insurance markets in individual states and regions. According to the CMS blog post, the agency is looking for the following: Waiver concepts that states could potentially use alone or in combination with other waiver concepts, state proposals, or policy changes; Waiver concepts that could advance some or all of the principles outlined in the 1332 Guidance released in 2018; Waiver concepts that incorporate the entire range of waivable requirements allowed under section 1332; and How states might combine the flexibilities available under 1332 with other flexibilities that exist under federal law, including regulatory flexibility, Section 1115 Medicaid waivers, as well as state law. Comments related to the RFI should be submitted to the public docket by July 2, 2019.

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

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Begin by creating your free Career Cast account, which can be found on the top right hand corner of the website. From there, you can upload and manage multiple resumes, browse through hundreds of job postings, and even research salaries of the positions in question! AMRPA members and affiliates may also purchase Posting Packages at a standard, premium, or platinum level. AMRPA members will receive a 50% discount on all job postings. For questions about our Career Center, please contact Anna Kruskop, AMRPA Member Services Associate, at akruskop@amrpa.org or 202-207-1120.

AMRPA Magazine / June 2019 51

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

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DISCOUNTS FOR MEMBERS 52 AMRPA Magazine / June 2019

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