AMRPA Magazine March 2019 by AMRPA

March 2019 â&#x20AC;¢ Vol. 22, No.3

March 2019 • Vol. 22, No. 3

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

AMRPA Magazine, Volume 22, Number 3 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. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color. Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: 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 ©2019 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.

Table of Contents Letter from the Chair

Legislative Update

Moving Target: Is Medicare Manual Guidance Binding?

Comparing IRF-PAI Quality Measures Across Post-Acute Settings

AMRPA Submits Comments to CMS and RAND on SPADEs Beta Test Preliminary Results

MedPAC Issues Post-Acute Care Payment Recommendations for FY 2020

AMRPA Responds to MedPAC’s Payment Recommendations for Inpatient Rehabilitation Hospitals/Units

AMRPA Submits Comments to the National Quality Forum (NQF) Regarding Transfer of Health Information Measures Under Consideration for IRF QRP

GAO Evaluates CMS Episode-Based Models and Participants

2019 Medicare Participating Post-Acute Care Providers in the U.S.

2019 IPPS-Excluded Inpatient Rehabilitation Hospitals and Units, Long-Term Care Hospitals, CORFs and Beds By State

Comprehensive Dementia Care May Reduce Admissions to Long-term Care Facilities

Team-based Care Transformation in Primary Care Settings May Improve Care of Chronically Ill Patients

AHRQ Analysis Finds Hospital-Acquired Conditions Declined By Nearly 1 Million

Study Examines Functional Status 10 Years Post Severe Traumatic Brain Injury

Robotic Exoskeletons May Offer Health Benefits for Spinal Cord Injury Patients

Latest Research Findings

AMRPA Congressional News Center

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AMRPA Magazine / March 2019

Letter from the Chair

Looking at Legislative Priorities We are an association representing the inpatient rehabilitation hospital community and we always want to make sure that we are addressing the most critical issues facing our field, including the patients and families in our care. To that end, an ad hoc group of our Legislative and Policy Committee and our Washington-based staff recently came together to look at our legislative and regulatory priorities. The participants represented a diverse group of our members.

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

While the group established priorities for the coming year, it was understood that external forces often require our association to divert resources in order to address unanticipated issues and changes in anticipated issues. As an example of an anticipated issue, our association will need to address CMS’s annual proposed rule that would affect our industry into 2020. An example of an unanticipated issue was CMS’s suggested change in their interpretation of the role that therapy students might play in providing care to patients in rehabilitation hospitals. At the end of the day, CMS stated that student therapists may participate in therapy provided in an inpatient rehabilitation hospital if the student was appropriately supervised, and that the time spent with the student may count toward satisfying intensity of therapy requirements. Unanticipated resources were required to successfully advocate CMS so that its interpretation of students’ roles better aligned with the needs of our industry. After significant deliberation and discussion, the group created a list of legislative priorities going forward. The list includes both short-term and long-term priorities that would drive our legislative and regulatory efforts into 2019. The initiatives include but are not limited to: Oppose reimbursement cuts to IRFs Medicare audit reform Sound development of a unified post-acute care prospective payment system including pilot testing Medicare Advantage accountability Oppose prior authorization for IRF stays Quality measures and engage CMS as it develops CMG definitions and continue to support development and adoption of functional status measures Regulatory relief Payment flexibility Discharge planning transparency Many changes and challenges are coming in the next few years and we all need to remain focused and involved. We understand the potential impact of any one of these issues on our field and their effect on patient level outcomes. To be effective in addressing these priorities we need a strong cohesive voice. I cannot overstate the role you and your patients have in advocating for our field. I urge you to get involved, join an AMRPA committee and speak to your congressional offices about these issues. We are ready and willing to offer assistance as you reach out to your congressional offices.

AMRPA Magazine / March 2019

2019 Spring Conference & Congressional Fly-In March 10-12, 2019 â&#x20AC;˘ Ritz Carlton Pentagon City Hotel â&#x20AC;˘ Arlington, VA

AMRPA Magazine / March 2019

Legislative Update

Budget Outlook: Congressional Conference Committee Tackles FY 2019 Spending Deal After the longest running shutdown in U.S. history, Congress is back to regular order. On January 25, the president signed a spending bill (H. J. Res. 28) that ended the partial government shutdown, funding the previously closed agencies through February 15.

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

Highlights: »»

During the annual State of the Union address, President Trump urged Congress to pass legislation to lower prescription drug prices and overall health care costs.

»»

Congress and the Trump administration averted another partial government shutdown after coming to an agreement on a bill that contained $1.375 billion for new and replacement barriers along the U.S.-Mexico border and provided full funding for the remaining federal agencies through Fiscal Year (FY) 2019.

»»

Congressional committees begin intense focus on the rising costs of prescription drugs.

»»

Expansion of the CMS Innovation Center’s Value-Based Insurance Design (VBID) model includes testing coverage of Medicare's hospice benefit.

To summarize briefly the state of play leading up to this finale, a bipartisan Conference Committee was tasked with crafting a border security deal and finalizing the remaining Fiscal Year (FY) 2019 appropriations bills to keep the government open. On February 13, the Committee released details of the agreement and legislative text, which included $1.375 billion for border funding. On February 14, the Senate voted 83-16 to advance the spending package, and the House also quickly passed the bill with a vote of 300-128. Although the president signed the bill, avoiding another shutdown, he also officially declared a state of emergency in order to garner additional funding for a border wall. House Speaker Nancy Pelosi (D-Calif.) stated that the House will review its options and may file a lawsuit against the administration since the president decided to move forward with an emergency declaration. Several Republican lawmakers urged the president against declaring a state of emergency due to the precedent it sets for potential actions of future presidents. A coalition of 16 Democratic attorney generals filed suit on February 18, challenging the constitutionality of President Trump’s move to access additional funding for a border wall. It is expected that the declaration will be tied up in the courts for the foreseeable future. The president presented his annual State of the Union address to Congress on February 5, where he called on Congress to pass bipartisan legislation that addresses price transparency and lowers prescription drug prices. He stated that hospitals, insurance companies and drug companies should be required to disclose real prices to patients in order to drive costs down. President Trump also directed Congress to find ways to ensure patients with pre-exiting conditions are protected. Additionally, he announced an effort to eradicate HIV in 20 years and $500 million for childhood cancer research. Due to the government shutdown, President Trump’s FY 2020 budget will not be released until mid-March and may be released in two parts. Topline numbers are expected during the week of March 11, followed by a full budget breakdown the following week. Drug Pricing at Congressional Forefront Lawmakers have kicked off the year with a strong focus on prescription drug pricing, reflecting the priorities of the Trump administration, the Democrat-controlled House, and the new Senate Finance Committee chair. House Oversight and Reform Committee Chair Elijah Cummings (D-Md.) announced the launch of a new investigation on January 14, sending letters to a dozen drug makers to request detailed information

AMRPA Magazine / March 2019

and documents about their pricing practices. The Committee held the first of several hearings on drug pricing on January 29, with experts calling on Congress to improve price transparency. Members from both sides of the aisle emphasized the need to re-evaluate the rules around drug patents and exclusivities, while several Democratic lawmakers made more pointed observations about rising insulin prices. Insulin prices were also highlighted at a Senate Finance Committee hearing on January 29, with Chair Charles Grassley (R-Iowa) pledging to “get to the bottom” of why prices continue to increase. Grassley also noted that a number of manufacturers had declined his invitation to testify before the Committee. Indicating he would be “more insistent” going forward, he has invited seven brand drug manufacturers to testify at a February 26 hearing. Future House and Senate hearings are likely to focus more on legislative proposals. Notably, Grassley has introduced legislation with Sen. Amy Klobuchar (D-Minn.) that would permit individuals to import prescription drugs from Canada. Other bipartisan efforts include the Right Rebate Act, which aims to prevent the misclassification of drugs under the Medicaid drug rebate program; and proposals to bolster generic competition by targeting “pay-for-delay” tactics and abuse of the Risk Evaluation and Mitigation Strategy (REMS) program. Democrats have offered several bills to allow Medicare to negotiate directly with manufacturers. Meanwhile, the Department of Health and Human Services (HHS) released a long-awaited proposed rule that would effectively ban drug manufacturers from providing rebates unless they are offered directly to patients at the pharmacy counter. HHS Secretary Alex Azar has said the proposal, which is a key part of the president’s drug pricing blueprint, would correct a system that favors high list prices in negotiations between pharmacy benefit managers (PBMs) and manufacturers. Secretary Azar has called on Congress to advance legislation that would enact the proposals in the commercial insurance market. Speaker Pelosi criticized the proposal, echoing insurers and PBMs who argue the rule would raise premiums and out-of-pocket costs for patients. Surprise Billing Policies Gaining Traction Support is building in Congress for a bipartisan effort to address so-called surprise medical bills. The White House held a recent roundtable discussion with patients on surprise billing, earning the president praise from Democrats for highlighting the issue. Speaker Pelosi has made clear that addressing surprise medical bills is a key part of Democrats’ health care agenda. Sen. Lamar Alexander (R-Tenn.), chair of the Health, Education, Labor and Pensions (HELP) Committee, has met with other committee leaders on the matter and expects to see bipartisan legislation in the coming months. The details of such legislation is uncertain, and the different proposals floated by several lawmakers advance their own solutions to the problem. A draft bill released by Sen. Bill Cassidy (R-La.), for instance, would cap patient’s out-of-pocket costs and prohibit balance

billing. In most cases, the amount a health plan must pay would be set by the state. A bill introduced by Sen. Maggie Hassan (D-N.H.) last session would set up a “binding arbitration” process in a surprise out-of-network billing situation. A reintroduced bill from House Ways and Means Committee Health Subcommittee Chair Lloyd Doggett (R-Texas) would require hospitals to notify patients whether the providers they would receive care from are in-network. Without sufficient notice and the patient’s consent, hospitals could charge patients no more than the in-network cost. Committee Examined ACA Case Effect on Pre-Existing Conditions On February 6, the House Energy and Commerce Committee held a Health Subcommittee hearing to examine Texas v. United States, the lawsuit challenging the ACA, and its potential impact on Americans with pre-existing conditions. Democrats criticized Judge Reed O’Connor’s decision that would invalidate the entire Affordable Care Act (ACA) on the basis that the individual mandate is inseverable from the law and warned that the lawsuit threatens coverage for millions of Americans, especially those with pre-existing conditions. Subcommittee Ranking Member Michael Burgess (R-Texas) stated that there is broad bipartisan support for protecting patients with pre-existing conditions. He noted that Texas v. United States has been stayed and is under appeal. Thomas P. Miller, Resident Fellow, American Enterprise Institute testified before the Health Subcommittee. He cast doubt on the likelihood that Texas v. United States will succeed in overturning the ACA. While he argued the plaintiffs are “not out of bounds,” seeing as they are relying on the Supreme Court’s 2011 decision, he expects that the law will be preserved even if the case does go the highest court. In the meantime, he added, Congress must overcome its inability to resolve problems with the ACA through legislative mechanisms. Ranking Member Burgess argued that the subcommittee should be holding hearings on prescription drug costs, Medicare for All and solutions to improve the ACA. Subcommittee Chair Anna Eshoo (D-Calif.) confirmed that the subcommittee will hold another hearing soon to explore legislation that would address the administration’s expansion of short-term limited duration health plans and cuts to exchange enrollment activities. CMS Expanded VBID Model Announcement On January 18, the Centers for Medicare and Medicaid Services’ (CMS) Innovation Center announced the expansion of an existing Value-Based Insurance Design (VBID) model. Although it is being described as a drug pricing initiative, in actuality it is more focused on broader private plan initiatives to improve care through coordination, telemedicine, wellness incentives, and other delivery system approaches. In the 2021 plan year, the model will allow plans to test coverage of Medicare's hospice benefit. After a relatively quiet two years, the announcement comes as the Innovation Center is expected to move forward with several new demonstrations and pilots that test different care delivery models. HHS Notice of Benefit and Payment Parameters for 2020 On January 17, the Centers for Medicare and Medicaid Services (CMS) released its proposed 2020 Notice of Benefit and Payment Parameters for the Affordable Care Act (ACA) exchanges.

AMRPA Magazine / March 2019

The annual rule proposes a number of new policies, including reducing the user fee for federally-facilitated exchanges and state-based exchanges; increasing the maximum out-of-pocket spending levels for exchange plans; allowing mid-year drug formulary changes; and creating a new special enrolment period for enrollees who become eligible for subsidies following a decrease in income. Medicare Advantage and Part D Advance Notice and Draft Call Letter CMS on January 30 released Part II of the 2020 Draft Call Letter and Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part D Payment Policies. Among other changes, the notice proposes new flexibilities for MA plans to offer supplemental benefits for chronically ill beneficiaries. The notice also includes proposals to combat the opioid epidemic by expanding Part D beneficiary access to naloxone. CMS will accept comments on all proposals in Part I and Part II through March 1, 2019, before publishing the final Rate Announcement and Call Letter by April 1, 2019. HIT Proposed Rule Seeks Comment on Adoption in PAC Settings On February, 11, the Department of Health and Human Services (HHS) today released two proposed rules to improve the interoperability of electronic health information. The first rule, released by CMS, proposes changes to support the MyHealthEData initiative to improve patient access and advance electronic data exchange. The proposed rule also includes two Requests for Information (RFIs) seeking feedback on interoperability and health information technology adoption in post-acute care (PAC) settings, and the role of patient matching in interoperability and improved care. Additionally, the Office of the National Coordinator of Health Information Technology (ONC) released a proposed rule to implement provisions in the 21st Century Cures Act related to patient access, information

AMRPA Magazine / March 2019

blocking, new conditions of certification and application programming interfaces (APIs). VA Proposed Access Standards The Department of Veterans Affairs on January 30 announced new proposed access standards for community care and urgent care. The new access standards, expected to be effective in June, will be based on average drive time and appointment wait times. The VA is proposing appointment wait-time standards of 20 days for primary care, mental health care and non-institutional extended care services, and 28 days for specialty care. Veterans who cannot access care within the new standards would be able to choose to seek care at an eligible community provider. *** March will be busy a month, as the President’s Proposed FY 2020 Budget Blueprint is expected to be released. Although often considered obsolete upon the moment of release, it will contain policies and potentially “pay-fors” that lawmakers could use for future legislation. We believe that post-acute care could be targeted for budgetary cuts. Therefore, your presence and participation on March 11-12 in Washington at AMRPA’s upcoming Leadership Conference in Fly-In is critical to the future of rehab hospital field care! AMRPA as a field is challenged to educate the more than 100 new Representatives in the 116th Congress on how critically important and medically necessary rehabilitative care is for its patients and the unique role of rehabilitation hospitals in the continuum of care. We will help set up meetings for you and your colleagues on Capitol Hill with your Members of Congress and Senators, and provide you with talking points on the fields’ most pressing policy issues. Also, be on the lookout for an upcoming AMRPA webinar to help prep for the Fly-in and convey AMRPA’s important message to Congress! Please be in touch and please plan to actively participate – we need you.

2019 FALL

2019

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

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

Abstract Deadline: May 6, 2019

What would you like to discuss this year? Submit your abstracts for AMRPA’s 17th Annual Educational Conference & Expo! AMRPA encourages you to share your knowledge, case studies, and experience in these 5 categories:  Business Operations & Leadership Management  Clinical Care Delivery: A Team Approach  Regulatory, Legislative, and Accreditation Matters  Marketing and Relationship Management  Other

Submit your ideas today! For more information about how to submit your abstract, visit the AMRPA website:

https://amrpa.org/abstract-submission Questions about submitting your abstract? Contact Julia Scott, AMRPA Member Services Coordinator, at jscott@amrpa.org for assistance.

#AMRPA

AMRPA Magazine / March 2019

Moving Target: Is Medicare Manual Guidance Binding?

Peter W. Thomas, Principal, The Powers Law Firm

Ronald S. Connelly Principal, The Powers Law Firm

There have been many developments in the courts and federal policy that call into question whether guidance issued by the Centers for Medicare and Medicaid Services (CMS) is actually binding. CMS maintains that the provisions of the Medicare manuals are binding, including the Medicare Benefit Policy Manual (MBPM) section governing rehabilitation. Therefore, all inpatient rehabilitation hospitals and units (IRH/Us) should absolutely continue to fully comply with all the guidance regarding patient admissions and coverage criteria. Nonetheless, there are two recent events that may impact the rehabilitation field. The Department of Justice (DOJ) has issued revisions to its manuals that will lessen the impact of the policies on guidance that were announced under the prior Attorney General, Jeff Sessions. Also, the Supreme Court recently heard arguments on a Medicare case that could substantially limit the role of guidance in the Medicare program. As we have reported previously, in 2017, a federal district court held that some of the “standards” in Chapter 1, Section 110.1 of the MBPM for IRH/U admissions cannot be applied as mandatory and that a portion of this section of the manual does not merely clarify the requirements of 42 C.F.R. § 412.622(a)(4).1 Rather, the manual creates substantive requirements that are not enforceable because they were not issued as regulations in compliance with the notice and comment rulemaking procedures of the Administrative Procedure Act (APA). In Cumberland County Hospital System, Inc. v. Price, the court overturned several IRH/U claim denials, determining that the MBPM requirements for the preadmission screening went beyond what was required under the regulation. Since the decision in Cumberland County, additional developments continue to call into question CMS’s reliance on manual guidance as the basis for claim denials. DOJ issued memoranda that indicated the unenforceable nature of such guidance. Then, more recently, the DOJ walked back its position, specifically with respect to Medicare guidance. And, an important case currently pending at the Supreme Court may prove to be the final source of clarity on this point. We will discuss the status of that case—Azar v. Allina Health Services—at the end of this article.

Christina A. Hughes Counsel, The Powers Law Firm

DOJ’s Position on Manual Guidance In November 2017, then-Attorney General Sessions issued an internal memorandum stating that DOJ must “use, in most cases, notice-and-comment rulemaking when purporting to create rights or obligations binding on members of the public or the agency.”2 Sessions emphasized that “guidance may not be used as a substitute for

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See Cumberland Cty. Hosp. Sys. v. Price, No. 5:15-cv-319-D, 2017 WL 1048102 (E.D.N.C. Mar. 1, 2017). Memorandum from Attorney Gen. Jefferson B. Sessions III to All Components, U.S. Dep’t of Justice 1 (Nov. 16, 2017) (available at https://www.justice.gov/opa/press-release/file/1012271/download) (hereinafter “Sessions Memorandum).

rulemaking and may not be used to impose new requirements on entities outside the Executive Branch.”3 The memo directed that “[g]uidance documents should not use mandatory language such as ‘shall,’ ‘must,’ ‘required,’ or ‘requirement’ to direct parties outside the federal government to take or refrain from taking action, except when restating—with citations to statutes, regulations, or binding judicial precedent—clear mandates contained in a statute or regulation.”4 The Sessions Memorandum specifically applied to guidance documents created by DOJ. In January 2018, then-Associate Attorney General Rachel Brand issued a second memorandum applying the principles of the Sessions Memorandum to DOJ enforcement actions: [T]he Department should not treat a party’s noncompliance with an agency guidance document as presumptively or conclusively establishing that the party violated the applicable statute or regulation. That a party fails to comply with agency guidance expanding upon statutory or regulatory requirements does not mean that the party violated those underlying legal requirements; agency guidance documents cannot create any additional legal obligations.5 The Brand Memorandum emphasized that DOJ attorneys cannot use non-compliance with agency guidance documents “as a basis for proving violations of applicable law” in affirmative civil enforcement actions.6 While the Sessions and Brand memoranda apply most directly to DOJ actions, they can also be said to articulate the proper role of agency guidance more generally. The memoranda’s reasoning could be applied to the MBPM. The Sessions and Brand memoranda suggested that guidance documents should not impose substantive requirements upon the regulated public unless those requirements are also present in a statute or regulation. Manuals such as the MBPM should only explain preexisting requirements. Instead, contractors routinely use the manuals to impose new requirements as the basis for denying IRH/U claims. After Sessions resigned as Attorney General, DOJ took steps to soften DOJ’s previously strong position on the role of guidance. In December 2018, DOJ issued revisions to its Justice Manual that alters DOJ’s position on agency guidance. The Justice Manual includes a section titled, “Limitation on Use of Guidance Documents in Litigation,” which at first restates the original position of Sessions: Criminal and civil enforcement actions brought by the Department must be based on violations of applicable

legal requirements, not mere noncompliance with guidance documents issued by federal agencies, because guidance documents cannot by themselves create binding requirements that do not already exist by statute or regulation.7 The Justice Manual now goes on to discuss the continued role such agency guidance may play in determining whether a party has nonetheless failed to comply with requirements established by the federal government: The Department may use a guidance document as probative evidence that a party has satisfied, or failed to satisfy, professional or industry standards or practices relating to applicable statutory or regulatory requirements. . . . This rationale applies more broadly in the health care arena, where guidance documents, like other statements of professional standards such as CMS’s Medicare Benefit Policy Manual or Local Coverage Determinations, are relevant evidence of violations of the principal requirement that procedures billed to Medicare or Medicaid be medically “reasonable and necessary.” E.g., 42 U.S.C. § 1395y(a)(1)(A); 42 U.S.C. § 1396 et seq.; 42 C.F.R. § 410.50. Such usage does not give these documents the force of law, but rather aids in demonstrating that the standards in the relevant statutory and regulatory requirements have been or have not been satisfied.8 The Justice Manual also bolsters CMS’s standard argument that manual guidance is binding by virtue of each health care provider’s voluntary enrollment in the Medicare program: “Additionally, when a government contract or provider agreement requires compliance with some agency guidance document, it is the contract—not the agency guidance itself— that makes the agency guidance pertinent and, in these cases, violations of that guidance undertaken with the requisite mental state may expose individuals to liability.”9 Under the memoranda issued by Sessions and Brand, it was possible to argue that CMS should not apply the MBPM and its provisions as mandatory requirements for IRH/U coverage because, if an appeal were ever to be pursued to federal court, DOJ would not have the authority to rely on those provisions as the basis for the denials. In light of the revised guidance—and indeed as maintained by CMS all along—this argument is more difficult to support. Under the current provisions of the Justice Manual, DOJ could argue that failure to comply with the MBPM is evidence that a claim is not reasonable and necessary. An IRH/U could also be pursued for failure to adhere to the requirements of its enrollment with CMS, which includes a certification of each provider’s compliance with “program instructions.”

Id. Id. at 2. 5 Memorandum from Assoc. Attorney Gen. Rachel Brand to Heads of Civil Litig. Components, U.S. Attorneys 2 (Jan. 25, 2018) (available at https://www.justice.gov/ file/1028756/download) (hereinafter “Brand Memorandum). 6 Id. 7 Dep’t of Justice, Justice Manual, Title 1, § 1-20.000, available at https://www.justice.gov/jm/1-20000-limitation-use-guidance-documents-litigation. 8 Id. at § 1-20.202. 9 Id. at § 1-20.204. 3 4

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Allina Supreme Court Case While DOJ’s clarifications in its Justice Manual hampers the argument that CMS should not apply manual guidance as binding requirements, a pending Supreme Court case has the potential to substantially impact this same issue. In Azar v. Allina Health Services, hospitals are challenging whether CMS has the authority to issue substantive and binding program requirements via anything less than notice-and-comment rulemaking.10 Importantly, the U.S. Court of Appeals for the District of Columbia has ruled that it may not.11 In its ruling, the D.C. Circuit determined that “the Medicare Act requires notice-and-comment rulemaking for any (1) ‘rule, requirement, or other statement of policy’ that (2) ‘establishes or changes’ (3) a ‘substantive legal standard’ that (4) governs ‘payment for services. Id. § 1395hh(a)(2).”12 The Court further determined that this requirement for rulemaking differs from the requirements of the APA and does not include the APA’s exemption of interpretive rules from notice-and-comment rulemaking. Under the reasoning of this ruling, potentially all of the substantive standards established in the Medicare manuals, including many of the provisions governing IRH/U admissions in the MBPM, could be invalidated because they were not subject to notice-and-comment rulemaking. Given the gravity and potential impact of the case, it is unsurprising that the government has appealed the decision to the Supreme Court. On January 15, 2019, the Supreme Court heard oral arguments. The government continues to maintain that the policy at issue (related to disproportionate share hospital (DSH) payments) is an interpretive rule permitted under the APA and that the Medicare Act does not impose different standards for rulemaking than those applied under the APA. The hospitals continued to argue that the Medicare Act imposes stricter requirements and that the DSH policy at issue failed to satisfy those requirements and is, therefore, invalid.

It is impossible to determine how the Supreme Court is likely to rule based only on oral arguments. It should be noted that Justice Kavanaugh wrote the opinion for the D.C. Court of Appeals, in his prior role as a judge on that court; as a result, he has recused himself from consideration of the appeal at the Supreme Court. This means that a 4-4 tie among the justices would result in the lower court’s decision being upheld. Among the various potential rulings are possibilities for a broad win for hospitals under which all guidance that changes or establishes substantive legal standards is ruled invalid, a narrower win overturning only the specific type of guidance at issue in the case, or a reversal in favor of the government. It is also possible that the Supreme Court could avoid the issue entirely by deciding that the DSH policy is a substantive rule that is invalid under the APA. Then, the Court would not have to decide the question of whether the Medicare Act imposes different rulemaking requirements because both the Medicare Act and the APA require notice-and-comment rulemaking for substantive rules. A decision is expected sometime this spring and certainly before the end of the Court’s session in June. Conclusion Given the rollback of DOJ’s position on agency guidance and the upcoming Supreme Court decision, the question of whether the MBPM provisions governing IRH/U coverage criteria are binding continues to be uncertain. Currently, in light of DOJ’s revised position, IRH/Us are in a weaker position to argue against application of the manual provisions as mandatory than at this time last year. Moreover, CMS will continue to maintain that each provider, by enrolling in Medicare, agrees to be bound by Medicare guidance. The Allina case could dramatically change the role of guidance in the Medicare program. In the meantime, IRH/Us are encouraged to do their utmost to ensure compliance with all standards set forth by CMS and to defend their rights aggressively through appealing denials that are based on anything other than compliance with the applicable regulations.

Azar v. Alina Health Servs., No. 17-1484, 2018 WL 2007202 (U.S., cert. granted Sept. 27, 2018). Allina Health Servs. v. Price, 863 F.3d 937 (D.C. Cir. 2017). Id., at 943.

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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.

Visit our Career Center Here:

https://careercenter.amrpa.org

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

AMRPA Magazine / March 2019 13

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Comparing IRF-PAI Quality Measures Across Post-Acute Settings Several changes have been made to the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI), Skilled Nursing Facility (SNF) Minimum Data Set (MDS), and Long-Term Acute Care Hospital (LTACH) Care Data Set since we reviewed them in 2016. It is time to provide an update on utilization of quality measures in other post-acute settings. This article offers a framework you can use as you adapt to the case-mix group (CMGs) changes coming our way in October 2019.

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

// It is time to provide an update on utilization of quality measures in other post-acute settings.

As you may know, the quality indicator requirements stem from the Improving Medicare Post-Acute Care Transformation (IMPACT) Act signed into law in 2014. The goal of the IMPACT Act was to standardize patient assessment data in order to enable data element uniformity, improve the quality of care and outcomes, allow comparison of data across post-acute settings, improve discharge planning, and offer exchangeability of data for coordinating care, per CMS. Fast forward to today, where LTACHs, SNFs, and home health providers are all adopting similar quality measures in their tools. For reference, the LTACH instrument is called the LTCH-Care Data Set. The SNFs use the MDS, and home health agencies use the Outcome and Assessment Information Set (OASIS). It is important to note that the data collection changes and updates begin on different dates for each instrument. Here we examine and compare quality measures across each instrument. Section B – Hearing, Speech and Vision The IRF-PAI and LTCH-CARE data set questions are almost the same – the LTCH CARE form asks if the patient is comatose while the IRF-PAI does not – but the MDS for SNFs has significantly more questions. The only standard items among all three data sets are the relatively new questions on the IRF-PAI regarding comprehension and expression. These are B0700 and B0800 on the IRF-PAI. Section C – Cognitive Patterns The IRF-PAI and MDS both include the Brief Interview for Mental Status (BIMS), but the LTCH-CARE Data Set does not. The MDS incorporates different questions for patients who are unable to participate in the BIMS assessment. In the LTACH and SNF settings, the Confusion Assessment Method (CAM) is used to assess delirium. However, the CAM is not identical on the LTCH-CARE and MDS instruments as the questions and responses are structured differently. The MDS includes several sections that are not on the IRF-PAI or LTCH-CARE Data Set, such as mood and behavior. The MDS previously included patient preferences for customary routine and activities but these questions have since been removed.

AMRPA Magazine / March 2019 15

Section G – Functional Status This item only appears on the MDS. It is assessed according to the rule of threes using a scale that grades Independence as a score of 1 and Total Dependence as a score of 4. Similar to our FIM™ measures, these items – in addition to the functional items in section GG – are used to generate the patient’s Rehabilitation Utilization Group (RUG) for the assessment period. Section GG – Functional Status All levels of post-acute services are utilizing section GG functional ability measures. Prior to October 2018, the uniformity among the items was sparse. Eating, oral hygiene and toileting hygiene appeared to be the only items that were exactly the same in the self-care area. Even in those cases, the scale that we use to measure the level of assistance was different on the MDS (whereas the LTCH-CARE data set and IRF-PAI use the same scale). In the mobility section, the instruments all had questions regarding the patient’s ability to move from sitting to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfers, toilet transfers, walk 50 feet with two turns, walk 150 feet, wheel 50 feet with two turns, and wheel 150 feet. Again, the scale used to grade the patient’s level of assistance was not consistent among the three tools. We did not have a one-to-one comparison within any of the functional status items. Fast forward to October 1, 2018, and you see a great deal more congruency among the tools: Section GG0100-Prior Functioning: Everyday Activities is the same on the MDS and IRF-PAI. There is one question regarding ambulation on the LTAC-CARE data set. GG0110- Prior Device Use is the same on all three instruments. Section GG0130 is the same on the MDS and the IRF-PAI. The LTAC-CARE data set includes only eating, oral hygiene, toileting and washing the upper body. The scale is the same for all three tools. The section GG0170 motor items are the same on the MDS and IRF-PAI. The LTAC-CARE data set does not include walking 10 feet on uneven surfaces, picking up an object, or stairs. The scale is the same for all three tools. We are getting closer to uniformity in the data collection that could one day form the basis for a payment system across the multiple levels of care. Section H – Bladder and Bowel All three instruments collect bladder and bowel data but the MDS differs here as well. Unlike the IRF-PAI or LTCH-CARE Data, MDS documents both appliances and urinary/bowel toileting programs use. Continence is noted for both Bowel and Bladder on all three instruments and the question is worded the same, but the responses or answers are not the same on the MDS as what we record on the IRF-PAI and LTAC CARE data set.

16 AMRPA Magazine / March 2019

Section I – Active Diagnoses In this section, the provider is asked to mark the patient’s conditions at the time of admission. The list of diagnoses to choose from continues to be different across all three instruments. Section J – Health Conditions This is the section where falls and prior surgery are recorded on the IRF-PAI. In the past, each tool would ask for falls data. The LTCH-CARE data set no longer captures data on falls. The question regarding prior surgery is not included on LTCH-CARE Data Set, but it is present in an expanded form on the MDS. Section K – Swallowing/Nutritional Status Each instrument asks for different information related to swallowing and nutrition status. Section M – Skin Conditions Each instrument assesses skin conditions. The information gathered is similar among all three instruments. However, the MDS asks for more detail regarding the patient’s pressure ulcers than the IRF-PAI or LTCH-CARE Data Set. Section N – Medications The drug regimen review questions asked on the IRF-PAI are the same as those asked on the LTCH-CARE data set. The MDS asks additional questions, but includes Section N 2001, 2003 and 2005 as well. Section O – Special Treatments, Procedures and Programs All three tools include a question regarding the flu vaccine and it is written in the same format. The IRF-PAI is the only tool that asks about total parenteral nutrition (TPN). The LTCH-CARE data set and the MDS have several additional questions in Section O that are not incorporated into the IRF-PAI. Though it appears that each level of post-acute care continues to gather data on different items, there are more similarities now between the data sets than existed two years ago. The items that are most interesting to watch are those that will impact the inpatient rehabilitation CMGs beginning in October 2019. My review indicates that the greatest amount of changes occurs in identifying commonalities in the section GG items. The instructions for data collection are the same; however, the difference in patient interaction could result in significantly varying performance across the levels of care. As we move closer to converting our CMGs from FIM™ to sections GG and H functional items, it is imperative to continue evaluating the way you collect data and how you engage staff in the documentation process.

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AMRPA Submits Comments to CMS and RAND on SPADEs Beta Test Preliminary Results Editor’s Note: On January 15, 2019, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Centers of Medicare and Medicaid Services (CMS) and the RAND Corporation on the development of cross-setting post-acute care (PAC) standardized patient assessment data elements (SPADEs) as required under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The complete letter is provided below and is available at www.amrpa.org.

January 15, 2019 Maria Edelen, Ph.D. Senior Behavioral Scientist RAND Corporation 1200 S. Hayes Street Arlington, VA 22202 Submitted electronically to spadeforum@rand.org Re: Early Findings from the RAND IMPACT Act National Beta Test of Standardized Patient Assessment Data Elements Dear Dr. Edelen: These comments are submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) with respect to the above captioned Request for Stakeholder Input. We welcome the opportunity to offer feedback on the development of standardized patient assessment data elements (SPADEs) pursuant to the requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. AMRPA supports the principles and objectives of the Act and remains committed to working with the Centers for Medicare and Medicaid Services (CMS) and its contractor, the RAND Corporation, to achieve them. AMRPA is the national trade association representing more than 625 freestanding inpatient rehabilitation hospitals and rehabilitation units of general hospitals (referred to as inpatient rehabilitation facilities (IRFs) by Medicare), outpatient rehabilitation service providers, and several long-term care hospitals (LTCHs) and skilled nursing facilities (SNFs). Inpatient rehabilitation hospitals and units (IRH/Us) provide hospital-level care, which is significantly different in intensity, capacity, and outcomes from care provided in non-hospital post-acute settings. AMRPA members help patients maximize their health, functional skills, independence, and participation in society so they can return to home, work, or an active retirement. With our Quality Committee and member clinicians, AMRPA has reviewed the SPADEs national beta test preliminary results presented by RAND and CMS staff at the November 27, 2018 stakeholder forum. Our following comments are divided into two sections: I. General comments and recommendations regarding the development of the SPADEs, and II. Specific questions pertaining to RAND’s presentation slides from the stakeholder forum. AMRPA appreciates CMS’ continued transparency and willingness to engage post-acute care (PAC) stakeholders in developing the SPADEs. We look forward to reviewing the forthcoming summary report on this work. I. General Comments A. Setting-Specific Findings While the data presented in November were highly informative, they were overall results aggregated across all four post-acute care settings. AMRPA

AMRPA Magazine / March 2019 19

requests that CMS/RAND make setting-specific beta test results and data available. It would be helpful for stakeholders to see feedback from the participant sites on the items’ potential for improving quality, and particularly an item’s clinical relevance to PAC or value added to existing care practices. B. Quantifying SPADEs’ Utility to Describe Case Mix One of the criteria used to evaluate the candidate SPADEs is “Utility for describing case mix.” It appears that RAND’s evaluations of this criterion so far have been qualitative in nature, i.e., derived from stakeholder input and beta test assessor surveys and focus groups. AMRPA recommends that RAND quantitatively assess the SPADEs’ utility in differentiating patient case mix. It would be very worthwhile to see if any of the items are actually able to differentiate patients within one PAC setting or among PAC settings. AMRPA has a strong appreciation for CMS’ view that SPADEs are being developed for multiple purposes not limited to payment-setting or resource utilization, such as facilitating clinical information transfer and improving care coordination. Nonetheless, CMS and RAND should methodologically evaluate the merits of the candidate items especially with regard to their ability to distinguish case-mix within and among PAC settings. This analysis should also examine whether the SPADEs items are psychometrically sound and look at potential floor or ceiling effects. To illustrate, several beta test SPADEs are already being reported by all IRH/Us on the IRF PAI, including the Expression and Understanding Cognitive Status items. Based on FY 2017 data however, these items show a ceiling effect when used for IRH/U patients, with more than half of all patients scoring at the highest-functioning level for these items (see data below).1 Assessment items that exhibit a ceiling effect for inpatient rehabilitation patients, such as these, are ill-suited for patient classification and case-mix purposes. AMRPA recommends that RAND rigorously analyze candidate SPADEs’ utility for case-mix purposes and include this assessment in its overall evaluation of each item’s suitability for future use. IRF PAI Scoring Distribution, FY 2017 N Scores

IRF PAI Item BB0700: Expression of Ideas and Wants

9,958

30,616

135,731

193,085

Percent of all patients

2.7%

8.3%

36.7%

52.2%

IRF PAI Item BB0800: Understands Other Code

6,109

34,438

140,227

188,616

Percent of all patients

1.7%

9.3%

37.9%

51.0%

C. Cognitive Status With regard to cognitive status, many PAC patients are somewhere between the extremes of severely cognitively impaired and highly cognitively functional. Although the Brief Interview for Mental Status (BIMS), Confusion Assessment Method (CAM), and other candidate Cognitive Status SPADEs might distinguish between highly functional or severely impaired cognitive status, AMRPA and our members have significant reservations that these items are able to capture the full range of PAC patients’ cognitive impairment. As described above, the Expression and Understanding items show a ceiling effect for rehabilitation hospital patients. Similarly, for the BIMS, AMRPA remains concerned that it is not sensitive enough to capture the range of cognitive impairments exhibited by IRH/U patients. Our members report that many patients who score the highest/most functional score on BIMS in fact have mild to moderate cognitive deficits which are not being captured by the BIMS. As designed for the Continuity Assessment Record and Evaluation (CARE) Item Set used in the Post-Acute Care Payment Reform Demonstration (PAC PRD), the BIMS is a gateway item for the CAM, which is triggered when responses to the BIMS suggest the presence of cognitive impairment. Currently, IRH/Us only report the BIMS on the IRF PAI. As AMRPA has expressed to CMS previously, we do not think the BIMS alone is sufficiently sensitive to measure the cognitive deficits of inpatient rehabilitation patients. We recommend that RAND examine if using the BIMS in combination with the CAM (as done in the beta test) produces a more sensitive cognitive assessment tool. We are particularly interested in seeing this data, and all Cognitive Status SPADEs data, specific to IRH/U patients. We appreciate RAND’s recognition, as expressed during the stakeholder forum, that the cognitive status items used and tested to date may be too simplistic to

RTI International, Analyses to Inform the Potential Use of Standardized Patient Assessment Data Elements in the Inpatient Rehabilitation Facility Prospective Payment System, C-4 (Apr. 2018).

20 AMRPA Magazine / March 2019

capture the full range of cognitive functional deficits seen in PAC. Unfortunately, this important domain remains an inadequately captured aspect of patients’ clinical profiles. AMRPA and our members welcome the opportunity to continue working with CMS to improve how cognitive status is captured by providers and addressed by Medicare. D. Assessment Time As AMRPA has commented to CMS before, we do not think that the beta test’s results for time spent on each SPADE are representative of what it will actually take the average PAC provider to conduct these assessments. The beta test participants have benefitted from highly specialized training by CMS and RAND staff, been provided with an electronic assessment tool (a tablet), and could readily turn to CMS/RAND staff as resources for any questions that arose during assessments. Furthermore, it is highly likely that the staff chosen by beta test sites to be the assessors were the facilities’ more experienced staff members. These are simply not the conditions that PAC providers would actually face in their day-to-day operations. The assessment times from the beta test’s relatively controlled testing environment do not necessarily reflect the provider burden if SPADEs were collected as part of PAC patient assessment instruments (PAIs). We ask CMS to be cognizant of these factors should it consider adding SPADEs to PAIs. E. Burden on Patients and Fatigue Finally, we remind CMS and RAND to be mindful of the impact that numerous assessments or patientreported questions could have on the patient-provider relationship. We believe this aspect has been an unevaluated, yet critical, component to the successful implementation of PAC assessment items. Would patients be receptive to the breadth of information being collected from them and on them? To some patients such as the elderly, frail, and those with cognitive deficits, so many questions can seem intrusive and patients may respond negatively to an exhaustive battery of assessment minutiae. Our members also report seeing some patients, such as those with cognitive impairments, lose focus after being asked so many questions. This may also muddle the accuracy of patient-reported data. II. Questions Regarding the November 27, 2018 Presentation Slides The following are questions pertaining to specific slides from the stakeholder forum. We would appreciate clarification and/or additional information from RAND on these topics. • Slide 18: There appears to be a much lower percentage of completed discharge assessments compared to admission assessments, and differences in completion 2 3

rates across settings. What are the factors contributing to these results? How does the low volume of discharge assessments impact the completeness of test results? HHA

IRF

LTCH

SNF

Overall

Total Admission Assessments

653

794

507

1167

3121

Total Discharge Assessments

148

349

235

823

Discharge Assessments as

23%

44%

18%

20%

26%

Scores

% of Admission Assessments

• Slide 24, “Overall Evaluation of Candidate SPADEs” colored grid: How did RAND conduct this evaluation? Was it based on beta test participant feedback or RAND staff’s impression of the SPADEs? We would appreciate more background information about how this grid was developed.

• Slide 69: Based on assessor feedback, the Special Services, Treatments, and Interventions (SSTI) SPADEs were of “low clinical utility in IRFs.” What does CMS or RAND intend to do with items that do not have high utility to PAC providers? AMRPA urges that only assessment items that demonstrate clear utility to PAC providers and add value to existing practices be considered for any future standardization across settings.

Conclusion AMRPA appreciates the opportunity to provide input on the development of cross-setting PAC standardized patient assessment data elements. We seek to ensure that these elements achieve the data collection objectives of the IMPACT Act while being minimally burdensome for PAC providers. If you have any questions, please contact Carolyn Zollar, J.D., Executive Vice President for Government Relations and Policy Development (czollar@amrpa.org), and Mimi Zhang, Senior Policy and Research Analyst (mzhang@amrpa.org) at 202-591-2469.

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

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

RTI International, Continuity Assessment Record and Evaluation (CARE) Item Set: Additional Provider-Type Specific Interrater Reliability Analyses, 21 (Sept. 2012). See AMRPA comment letter on the FY 2019 IRF PPS Proposed Rule (CMS-1688-P).

AMRPA Magazine / March 2019 21

2019 AMRPA Schedule of Events CONFERENCE DATES 2019 Spring Conference in Washington, DC March 10-11, 2019: Medical Directors Symposium March 11-12, 2019: Leadership Forum & Congressional Fly-In 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, California Sunday, October 13, 2019: IRF Boot Camp October 14-16, 2019: Fall Conference & Expo AMRPA MEMBERS ONLY CALLS Wednesday, April 17 at 1:00 p.m. ET 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 AMRPA WEBINARS Tuesday, March 5: Hill Prep Webinar for 2019 Leadership Forum Attendees at 1:00 p.m. ET Look out for additional AMRPA webinars in the next issue! eRehabData® WEBINARS: AVAILABLE TO eRehabData® SUBSCRIBERS ONLY Tuesday, March 12: Improving Discharge to Community Rates Tuesday, April 2: Nursing and Therapy Documentation Tips Tuesday, May 7: Physician Documentation Tuesday, June 4: Managing Outcomes with eRehabData

Please visit www.amrpa.org for registration information. 22 AMRPA Magazine / March 2019

MedPAC Issues Post-Acute Care Payment Recommendations for FY 2020 On January 17, the Medicare Payment Advisory Commission (MedPAC) met to vote on its fiscal year (FY) 2020 payment recommendations for inclusion in its March 2019 Report to Congress on Medicare payment policy. In advance of the meeting, AMRPA submitted a letter to MedPAC providing our comments on the recommendations and specifically to urge their rejection. The letter is reproduced in this issue of the magazine.

Mimi Zhang, AMRPA Senior Policy and Research Analyst

Highlights: »»

»»

For inpatient rehabilitation hospitals/units, MedPAC reiterates its prior recommendation to lower the payment update by five percent in FY 2020. For long-term care hospitals, MedPAC changed course between its draft and final recommendations to ultimately recommend a two percent payment increase.

An article in last month’s issue of the AMRPA magazine covered the anticipated recommendations for inpatient rehabilitation hospitals and units (IRFs) and the state of the field in depth. As that issue went to press, the commission proceeded to finalize its recommendation to reduce IRF payments by five percent for FY 2020. The commission will also reiterate its recommendations for the Secretary of the Department of Health and Human Services (HHS) to expand the high-cost IRF outlier payment pool and to conduct targeted medical reviews to study the interrater reliability of patient assessments. MedPAC has recommended this since March 2016, though neither Congress nor the Centers for Medicare and Medicaid Services (CMS) have acted on the recommendations to date. This article summarizes the commission’s FY 2020 recommendations for post-acute care providers (IRFs, long-term care hospitals [LTCHs], skilled nursing facilities [SNFs], and home health agencies [HHAs]), and the commission’s findings on potential implications. The recommendations will be included in MedPAC’s forthcoming Report to Congress that is typically released in mid-March. Inpatient Rehabilitation Hospitals and Units In 2017, the supply and volume of inpatient rehabilitation providers remained steady, and quality has been improving since 2012. The aggregate Medicare margin for the sector in 2017 was 13.8 percent, and the projected aggregate Medicare margin for 2019 is 11.6 percent. Of note, Medicare fee-for-service (FFS) beneficiaries constituted 58.8 percent of all IRF patients in 2017 after holding steady at 60 percent for several years. Commission Recommendation: The Congress should reduce the fiscal year 2020 Medicare payment rate for IRFs by 5 percent. Implications: Spending: Decrease relative to statutory update by between $250 million and $750 million in 2020 and by between $1 billion and $5 billion over five years. Beneficiary and provider: No adverse effect expected on Medicare beneficiaries’ access to care or out-of-pocket spending. May increase financial pressure

AMRPA Magazine / March 2019 23

on some providers, but the effect should be eased by an accompanying expansion in the outlier pool (as recommended previously). Long-Term Care Hospitals Under the LTCH prospective payment system (PPS), cases that are excluded from the acute care hospital payment rate (IPPS) and are thereby eligible to receive the higher LTCH PPS rate must meet two criteria. They must 1) be preceded by an acute care hospital discharge, and 2) either spend three or more days in the ICU of the referring acute care hospital or receive prolonged mechanical ventilation in the LTCH. All other cases are paid a lower “site-neutral” rate. In 2017, the Medicare margin for cases that qualified for the LTCH PPS rate was 4.6 percent. MedPAC projects a margin of 1.2 percent for 2019 for qualifying cases. LTCH occupancy, supply, volume and marginal profit all declined in 2017. Quality is stable for the limited available aggregate measures. At MedPAC’s December 2018 meeting, the commissioners expressed reservations about the draft payment recommendation proposed by MedPAC staff at the time, which recommended a zero update to the LTCH PPS in FY 2020. The commissioners asked MedPAC staff to adjust the recommendation to better take into account the low margins projected for the sector and other indicators of sector stability, such as the diminishing number of LTCH providers. Accordingly, MedPAC staff presented a revised recommendation for the commissioner’s vote at the January meeting. The commissioners voted in support of formalizing the revised recommendation. Commission Recommendation: The Congress should increase the FY 2020 Medicare base payment rate for LTCHs by 2 percent. Implications: Spending: Decrease relative to the statutory payment update by less than $50 million in 2020 and by less than $1 billion over five years. Beneficiary and provider: No adverse impact on beneficiaries expected. The update is not expected to affect providers’ willingness and ability to care for Medicare beneficiaries who meet the criteria. Skilled Nursing Facilities In 2017, the Medicare margin for SNFs was 11.2 percent and the projected Medicare margin for 2019 is 10.0 percent. According to MedPAC, the level of SNF payments remains too high relative to costs and the SNF PPS needs to be revised. Nonetheless, given the changes in store for the sector in FY 2020 due to the new Patient Driven Payment Model (PDPM), MedPAC says it proceeded “more cautiously” in its SNF recommendations this year. Specifically, the commission opted to recommend a zero update for the sector instead of a payment cut as it has done in previous years.

24 AMRPA Magazine / March 2019

Commission Recommendations: The Congress should: Eliminate the FY 2020 payment update to the SNF base payment rates. Direct the Secretary to proceed to revise the SNF PPS in 2020 and annually recalibrate the relative weights of the case mix groups to maintain alignment of payments and costs. Implications: Spending: Decrease relative to current law and MedPAC does not expect adverse impact to providers or beneficiaries given the high level of Medicare payments. The revised SNF PPS will increase the equity of Medicare's payments by increasing payments for medically complex care and decreasing payments for therapy-intensive care that is not related to a patient's condition. It would also narrow disparities in financial performance across SNFs. Access should increase for medically complex beneficiaries. Home Health Care MedPAC found that indicators of beneficiary access and provider supply are positive for the home health sector. Functional status quality measures show improvement while the rates of adverse events did not change significantly. However, MedPAC cautions that the functional status performance should be taken with a grain of salt because the data is provider-reported; MedPAC has expressed similar concerns about IRF-reported functional data. In 2017, the Medicare margin for HHAs was 15.2 percent, and the projected Medicare margin for 2019 is 16.0 percent. HHAs exhibited the highest margin of any sector in MedPAC analysis this year. Commission Recommendation: The Congress should reduce the calendar year 2020 Medicare base payment rate for home health agencies by 5 percent. Implications: Spending: Decrease relative to current law by $750 million to $2 billion in 2020 and $5 billion to $10 billion over five years. Beneficiary and provider: Lower payments should not affect beneficiary access to care or providers’ willingness to deliver appropriate home health care. *** These recommendations will be reflected in MedPAC’s March 2019 Report to Congress. MedPAC’s next public meeting takes place on March 7-8, 2019.

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AMRPA Responds to MedPAC’s Payment Recommendations for Inpatient Rehabilitation Hospitals/Units Editor’s Note: On January 16, 2019, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Medicare Payment Advisory Commission (MedPAC) regarding its draft recommendations relating to payments for inpatient rehabilitation hospitals and units (IRH/Us). The complete letter is provided below and is available at www.amrpa.org.

January 16, 2019 Francis J. Crosson, M.D. Chairman Medicare Payment Advisory Commission 425 Eye Street, N.W. Suite 701 Washington, DC 20001 Re: American Medical Rehabilitation Providers Association’s Comments on Chairman’s Draft Recommendations for Inpatient Rehabilitation Facilities for Fiscal Year 2020 Dear Chairman Crosson and MedPAC Commissioners: This letter is submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) to provide our comments on the Chairman’s draft recommendations relating to Medicare payments for inpatient rehabilitation facilities (IRFs). In summary, we respectfully urge the Commissioners to reject the Chairman’s draft recommendation to reduce the Fiscal Year (FY) 2020 IRF Prospective Payment System (IRF PPS) payment rate by five percent. AMRPA is the national voluntary trade association representing more than 625 freestanding rehabilitation hospitals, rehabilitation units of general hospitals, and outpatient rehabilitation service providers. Our members provide medical rehabilitation services in a vast array of health care settings working with patients to maximize their health, functional skills, independence, and participation in society so they are able to live as independently as possible by returning home, returning to work or, in many instances, pursuing an active retirement. In 2017, Medicare accounted for approximately 58 percent of IRF discharges.1 Medicare Margins During its December meeting, the Commission’s analysis of IRF payment adequacy focused on overall Medicare margins for all IRFs; however, as we have previously noted, this approach fails to recognize that margins vary substantially. MedPAC’s analysis found that most IRFs have nominal Medicare margins. The majority of IRFs are hospitalbased rehabilitation units (76 percent) that have an aggregate margin of 1.5 percent. A majority of IRFs are nonprofit (56 percent) and have aggregate margins of 2.2 percent. The Chairman’s draft recommendation of a five percent payment reduction to the IRF PPS base rate could have a significant and adverse effect for many IRFs and the patients served in these hospitals.

edPAC, Public Meeting Transcript (Dec. 6, 2018), M http://www.medpac.gov/docs/default-source/ default-document-library/december-2018transcript.pdf?sfvrsn=0, (last visited Jan. 1, 2019).

his data is derived from AMRPA’s analysis of T CMS’ FY 2019 Final Rule Inpatient Rehabilitation Facility Prospective Payment System rate setting files.

26 AMRPA Magazine / March 2019

We continue to be concerned that MedPAC has not revised its analysis to account for differences in the Commission’s projected 2017 aggregate IRF margin (14.3 percent) and the actual 2017 margin (13.8 percent). The 2017 actual margin is more than the 2016 aggregate IRF margin, but less than the 2015 margin. While AMRPA shares MedPAC’s desire to better understand the factors underlying variation in Medicare margins, we remain troubled by the continued suggestion that strong margins are due to patient selection or coding. For example, MedPAC seems to

presume that more profitable IRFs are selecting more patients with specific conditions like stroke without paralysis. Based on the literature we have seen, we do not believe there is evidence that differentials in patient coding meaningfully contributes to the variability. While we appreciate the Commission’s concerns regarding variation in Medicare margins, a five percent reduction is not the solution and, to the contrary, is likely to further exacerbate underlying financial disparities and potentially negatively affect patient access. In addition to the Medicare cost report data from the Centers for Medicare and Medicaid Services (CMS) that MedPAC used to complete its analysis, the IRS PPS Fiscal Year (FY) 2019 rate setting files provide additional information about the adequacy of Medicare payments to IRFs. Our analysis found that for FY 2019:2 44 percent of IRFs have negative Medicare margins (below 0 percent), and half of all rural IRFs have negative Medicare margins; 54 percent of all IRFs have margins below 5.0 percent; More than two-thirds of IRFs (64 percent) will have Medicare margins below 11.6 percent, MedPAC’s aggregate Medicare margin for all IRFs in FY 2020; and Across all IRFs, the average Medicare margin per facility will be 3.4 percent. Several important observations were offered during MedPAC’s December 2018 meeting, including the suggestion from one of the Commissioners that the Commission consider whether a more appropriate recommendation is to improve the uniformity of patient assessments rather than to reduce the payment rate. Additionally, the Commissioners discussed the discrepancies in payment recommendations between post-acute care providers with similar projected Medicare margins. Outlier Pool Expansion We continue to have concerns with the Commission’s standing recommendation to increase the outlier pool from three percent to five percent. MedPAC explains that the recommendation is intended to reduce misalignment between IRF payments and costs by redistributing payments. However, AMRPA opposes using outlier payment policy to arbitrarily redistribute funds among IRFs. There may be multiple reasons for outlier cases: complex patents known at admission, patients who develop unforeseen costly problems, higher cost structures and other factors. These factors suggest that expanding the outlier pool would not achieve MedPAC’s intended policy objectives of increasing outlier payments for the costliest cases while easing the burden for IRFs with a relatively large number of such cases nor truly help any providers negatively affected by the payment decrease. The outlier payment policy is a budget-neutral program. Increasing total outlier payments would further decrease the PPS base rate beyond the reduction the Commission is considering. Moreover, given the prospective nature of the outlier payment methodology, outlier payments have consistently resulted in a net loss that has taken money out of the IRF PPS system in recent years. This is certainly the case for individual IRFs that, despite their high costs, have fewer than average outlier cases. For

these reasons, increasing the outlier pool further risks reducing reimbursement for those IRFs that can least afford it. While AMRPA is eager to discuss with CMS and MedPAC potential ways to improve the effectiveness of the outlier pool policy, we oppose making changes to the outlier payment policy as a short-term solution to addressing variation in case-mix groups (CMGs). Additional Concerns During its December 2018 meeting, MedPAC outlined two concerns regarding IRF payments. Namely, IRFs with high margins have a different case mix than other IRFs, and IRFs may not be assessing patients’ functional ability in a uniform manner. As outlined above, the recommendation to implement an acrossthe-board five percent payment cut will not properly align IRF payments and costs. Instead, for a majority of IRFs, the draft recommendation would result in a negative Medicare margins. The recommendation fails to appropriately address MedPAC’s stated concerns regarding the IRF PPS. In light of MedPAC staff’s expressed concerns regarding the accuracy of provider-reported data, AMRPA affirms its support for the Improving Medicare Post-Acute Care Transformation (IMPACT) Act’s (P.L. 113-185) requirement for post-acute care providers to report on a standardized functional status quality measure. The law establishes the foundation for meaningful comparisons in quality and resource use by post-acute care providers. Functional status data is a key consideration for qualitative assessments, a determinate of the clinical appropriateness of care in the different settings, and a key predictor of resource use in post-acute care. Furthermore, as Commissioners observed at the November 2018 meeting, improving functional outcomes is the ultimate objective of postacute care. AMRPA views function as the most critical substantive quality measure under development and thinks functional status data should be a fundamental component of any unified postacute care payment system. Conclusion AMRPA appreciates the opportunity to provide the Commissioners with our comments on the important work you do. We welcome the opportunity to provide additional input throughout the process and to clarify any comments in this letter. If you have questions, please do not hesitate to contact Carolyn Zollar, AMRPA’s Executive Vice President of Government Relations and Policy Development, at (202) 223-1920 or czollar@ amrpa.org, or Martha Kendrick, AMRPA’s Washington Counsel, at (202) 887-4215 or mkendrick@akingump.com. Sincerely,

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

AMRPA Magazine / March 2019 27

AMRPA Submits Comments to the National Quality Forum (NQF) Regarding Transfer of Health Information Measures Under Consideration for IRF QRP Editor’s Note: In December and January each year, the National Quality Forum (NQF) Measure Application Partnership meets to review quality measures for the upcoming year’s Medicare rulemaking cycle, and solicits public comments as part of the process. The following is an abbreviated version of AMRPA’s comments to NQF on the Transfer of Information measures being considered for post-acute care quality reporting programs in the FY 2020 rulemaking. The measures are required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. AMRPA has submitted comments to CMS and NQF throughout the measures’ development process.

AMRPA appreciates the opportunity to provide input on the National Quality Forum (NQF) Measure Application Partnership’s (MAP) draft recommendations regarding the Transfer of Health Information Measures Under Consideration for the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) in the 2019 prerulemaking cycle. AMRPA supports the intent of the Transfer of Health Information measures and appreciates the additional information and clarifications provided by CMS staff during the December 10 NQF PAC/LTC MAP public meeting. Notably, CMS clarified that the differences between these Measures Under Consideration and the prior versions of the measures (made publicly available in spring 2018) are nominal in nature: The term “medication profile” was changed to “reconciled medication list” and the formal name of the measure was changed. With regard to the underlying technical measure specifications, CMS indicated that they are the same as the prior draft measure specifications, although she additionally noted that CMS’ guidance for what constitutes a medication list has been “pared down.” AMRPA appreciates CMS’ responsiveness to our and other stakeholders’ requests to scale back the measures and be less prescriptive in how providers reconcile medications and transfer that information for which IRFs, as hospitals, already have standard practices. Additionally, we are pleased to hear that CMS is incorporating certain beneficiary exclusions in the measure denominator for hospital-based PAC settings, such as excluding those patients discharged against medical advice (AMA). CMS staff also stated that they are developing additional measure guidance, such as the types of medications/interventions that define a reconciled medication list, that will be more granular than the technical measure specifications. If there have been changes made to the measures’ guidance (if not to the technical specifications), AMRPA respectfully requests that CMS make this information available to stakeholders as part of the NQF MAP process. We echo comments made by MAP members during the December meeting that there is still a need to resolve questions about the specific medication information the measures are intended to encompass and how providers would be expected to implement the measures. Needless to say, this guidance will shape the medication information transmitted at discharge/transfer and ultimately would impact how these measures will be operationalized across PAC settings. We impress upon NQF the importance of having this type of information available during the MAP public comment process. Without it, neither the MAP nor public stakeholders are able to truly respond to MAP’s questions for this comment opportunity, including “Do the potential benefits of the measure outweigh the burden of data collection or reporting?” or “What, if any, implementation challenges have you encountered for this measure?” Finally, because these measures are process measures, it is important for NQF and CMS to evaluate how provider performance would be validated. While some PAC settings are accredited by the Joint Commission and already adhere to medication reconciliation requirements, this is not standard practice across PAC settings. The Transfer of Health Information measures will be implemented across PAC settings and could potentially be

28 AMRPA Magazine / March 2019

viewed as a quality indicator to compare PAC settings. As such, it is critical for CMS to validate the reported data. In summary, while we support the non-prescriptive nature of these measures, we think CMS should still provide NQF and stakeholders more information about how the measures will be implemented and operationalized by PAC providers, and how CMS intends to validate the reported data.

A M E R I C A N M E D I C A L R E H A B I L I T AT I O N P R O V I D E R S A S S O C I AT I O N

Improving Access to Inpatient Rehabilitation Hospitals and Units www.AMRPAPAC.org

AMRPA Magazine / March 2019 29

GAO Evaluates CMS Episode-Based Models and Participants

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

Highlight: ÂťÂť

Providers participating in models tend to be larger and have higher spending.

In December 2018, the U.S. Government Accountability Office (GAO) released a report that examined Center for Medicare and Medicaid Innovation (CMMI) episode-based alternative payment model participant providers. The evaluation looked at characteristics and experiences of providers participating in the six episode-based, or bundled payment, models that CMMI has tested through 2018. The six models are the Bundled Payment for Care Improvement (BPCI) Model 1, BPCI Model 2, BPCI Model 3, BPCI Model 4, the Oncology Care Model (OCM), and the Comprehensive Care for Joint Replacement (CJR) Model. All of these models except for the CJR Model were voluntary, with the CJR being a partially voluntary and partially mandatory model. Size of Practice or Facility The report provided an analysis that compared the size of participating facilities or practices to their peers nationally. The GAO found that hospital participants in BPCI Models 1, 2 and 4, as well as CJR, had a mean number of beds that was at least 25 percent higher than the national mean. GAO did not do the same type of analysis for BPCI Model 3 as it did for other models. BPCI Model 3 is a post-acute care model in which skilled nursing facilities or home health agencies were paid based on 90-day episodes of care. Due to the differing types of post-acute care providers that participated in the model, GAO could not provide the same type of comparisons as it did for other models. Tables 8 and 9 at the end of this article compare the BCPI providers to national providers, divided by provider type. GAO also found that when it compared physician practices that participated in OCM to all Medicare physician practices, model participants tended to be larger. Specifically, GAO noted that OCM participating physician groups a mean of 42 physicians per group, compared to a mean of 14 nationally for all Medicare participating physician groups. Volume of Services The report also evaluated the episode volume of the type included in the models that were being delivered by model participants compared to other providers. The episode volume analysis used a baseline period to compare the participating and non-participating providersâ&#x20AC;&#x2122; services prior to the model commencing. GAO noted that participants in BPCI Models 2, 3, 4 and the OCM had a higher volume of relevant services in the baseline period compared to providers nationally. For BPCI Model 2, as an example, the report found that the mean of all BPCI-qualifying episodes per hospital nationally in 2016 was 1,598, while participants had a mean of 3,004 qualifying episodes that year. When looking at the OCM, the report noted that participating physician group practices had on average nearly four times as many attributed episodes than practices nationally.

30 AMRPA Magazine / March 2019

Episode Spending GAO also recognized differences in episode spending among participating and non-participating providers when using a baseline period for comparison. The report found that participating hospitals in most of the models had higher spending per episode during the baseline period than was the case for providers nationally. As an example, participating hospitals in BPCI Model 2 had a mean spending of $23,067 per episode in 2011, while non-participating providers had a mean of $21,690. Similarly, in the OCM, participating practices had a total mean spending of $27,386 per episode during the baseline period, while nationally that figure was $25,897. Location and Teaching Status There was also a notable difference in the locations and teaching status of providers when compared to national figures. The GAO observed that more than 90 percent of hospitals in BPCI Models 1, 2, and 4 were located in urban

areas, compared to only 75 percent of hospitals nationally. In addition, participating providers were more likely to be teaching hospitals or affiliated with teaching hospitals. The report found 57 percent of BPCI Model 1, 37 percent of BPCI Model 2 and 36 percent of BPCI Model 4 hospitals were accredited teaching hospitals. Comparatively, only 23 percent of hospitals nationally are teaching hospitals. For physician practices in OCM, 16 percent of the groups were affiliated with academic medical centers, compared to only 6 percent nationally. Table 2 below provides a breakdown of how participants in all of the models compared to Medicare providers nationally. The full table with footnotes can be found on page 11 of the GAO report. The GAO report is available for download at www.gao. gov/products/GAO-19-156.

Notes: Please see page 11 of GAO Report

AMRPA Magazine / March 2019 31

Notes: please see page 28 of GAO report.

Notes: Please see page 29 of GAO report.

32 AMRPA Magazine / March 2019

AMRPA Magazine / March 2019 33

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2019 Medicare Participating Post-Acute Care Providers in the U.S. The AMRPA magazine annually publishes statistics on the number of inpatient rehabilitation hospitals and units (IRH/Us), skilled nursing facilities (SNFs), long term care hospitals (LTCHs), home health agencies (HHAs), and comprehensive outpatient rehabilitation facilities (CORFs). The data is provided from CMSâ&#x20AC;&#x2122;s Online Survey, Certification and Reporting (OSCAR) database.

Type of Provider

1998

2000

2002

2004

2006

2008

2010

2012

Skilled Nursing Facilities (SNFs)

15,035

14,825

14,792

14,929

15,006

15,041

15,067

15,129

Home Health Agencies (HHAs)

9,386

7,528

6,935

7,341

8,587

9,382

10,945

12,121

Inpatient Rehabilitation Facilities (IRFs)

1,097

1,128

1,295

1,359

1,229

1,195

1,189

1,161

Long-Term Care Hospitals (LTCHs)

207

253

273

317

393

428

437

Comprehensive Outpatient Rehabilitation Facilities (CORFs)

550

516

544

638

627

517

401

295

2013

2014

2015

2016

2017

2018

2019

Skilled Nursing Facilities (SNFs)

15,685

15,712

15,189

15,233

15,279

15,643

15,581

Home Health Agencies (HHAs)

12,384

12,612

12,463

12,318

12,184

11,841

11,556

Inpatient Rehabilitation Facilities (IRFs)

1,162

1,161

1,172

1,179

1,186

1,178

1,166

Long-Term Care Hospitals (LTCHs)

436

430

424

427

424

410

385

Comprehensive Outpatient Rehabilitation Facilities (CORFs)

268

234

219

207

196

184

174

Type of Provider

Source: Centers for Medicare & Medicaid Services (CMS) OSCAR Database As of January 2019, CMS

AMRPA Magazine / March 2019 35

2019 IPPS-EXCLUDED INPATIENT REHABILITATION HOSPITALS AND UNITS, LONG-TERM CARE HOSPITALS, CORFS AND BEDS BY STATE The AMRPA magazine annually provides a breakdown of the number of inpatient rehabilitation hospitals and units (IRH/Us), skilled nursing facilities (SNFs), long term care hospitals (LTCHs) and comprehensive outpatient rehabilitation facilities (CORFs) and bed counts by state. The data is taken from CMSâ&#x20AC;&#x2122;s Online Survey, Certification and Reporting (OSCAR) database as of January 2019.

State ALASAKA

REHAB HOSPITALS

REHAB HOSPITAL BED COUNT

REHAB UNITS

REHAB UNIT BED COUNT

LTCH HOSPITALS

LTCH BED COUNT

CORFs

ALABAMA

427

291

353

ARIZONA

606

365

243

ARKANSAS

521

333

302

CALIFORNIA

538

1,959

1,630

COLORADO

297

272

400

CONNECTICUT

107

665

DELAWARE

DISTRICT OF COLUMBIA

137

142

FLORIDA

1,222

1,367

1,605

GEORGIA

324

554

718

HAWAII

100

IDAHO

114

100

ILLINOIS

533

1,175

948

INDIANA

438

617

489

IOWA

235

KANSAS

356

198

131

KENTUCKY

349

350

630

LOUISIANA

628

551

1,360

MAINE

100

MARYLAND

151

189

MASSACHUSETTES

722

2,887

MICHIGAN

174

939

826

MINNESSOTA

311

346

MISSISSIPPI

315

380

MONTANA

MISSOURI

461

499

349

NEBRASKA

142

151

204

NEVADA

251

336

369

NEW HAMPSHIRE

185

NEW JERSEY

781

263

544

NEW MEXICO

230

123

106

NEW YORK

150

1,366

686

NORTH CAROLINA

281

746

473

36 AMRPA Magazine / March 2019

State NORTH DAKOTA

REHAB HOSPITALS

REHAB HOSPITAL BED COUNT

REHAB UNITS

REHAB UNIT BED COUNT

LTCH HOSPITALS

LTCH BED COUNT

CORFs

OHIO

684

834

1,320

OKLAHOMA

182

416

519

OREGON

148

PENNSYLVANIA

1,449

1,285

692

PUERTO RICO

103

RHODE ISLAND

495

SOUTH CAROLINA

458

373

308

SOUTH DAKOTA

TENNESSE

612

498

362

TEXAS

3,453

1,725

4,067

UTAH

124

167

135

VERMONT

VIRGINIA

415

454

492

WASHINGTON

162

303

120

WEST VIRGINIA

290

WISCONSIN

171

388

204

WYOMING

293

18,498

873

20,988

385

26,242

174

TOTAL

AMRPA Magazine / March 2019 37

Comprehensive Dementia Care May Reduce Admissions to Long-term Care Facilities

Highlight: ÂťÂť

Comprehensive dementia care programs may help more patients stay in community-based settings.

An estimated 4 million to 5 million Americans have Alzheimerâ&#x20AC;&#x2122;s disease or another type of dementia. A recent study published in the JAMA Internal Medicine sought to determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-forservice beneficiaries. Older adults with dementia have greater postacute care use, and there is growing attention to the unique post-acute care needs of people with cognitive impairment.

// Older adults with dementia have greater post-acute care use, and there is growing attention to the unique postacute care needs of people with cognitive impairment.

The study compared health care utilization and costs for 1,083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2,166 similar patients with dementia not participating in the program.

Under the Dementia Care program, patients were co-managed by nurse practitioners and physicians. The program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, seven days per week. Patients in the comparison cohort were selected using the ZIP code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. Medicare claims data were used to compare utilization and cost outcomes for the two groups. The main outcomes and measures were admissions to long-term care facilities; average difference-in-differences per quarter over the three-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates.

38 AMRPA Magazine / March 2019

Notably, participants in the Dementia Care program (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a longterm care facility (hazard ratio, 0.60; 95 percent CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95 percent CI, −$1198 to −$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of −$284 (95 percent CI, −$881 to $312) per program participant per quarter.

The authors concluded that comprehensive dementia care may reduce the number of admissions to long-term care facilities than patients in a propensity score–matched control group, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help persons with dementia stay in their communities. For the study see, Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries, JAMA Internal Medicine 2019;179(2):161-166, December 21, 2018.

JOIN TODAY!

EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE

AMRPA: Working Together Access to Medical Rehabilitation AMRPA: Working Together to To Preserve Preserve Access To Medical Rehabilitation Maggie Ramirez · VP of Membership · 347-573-3732 · mramirez@amrpa.org Chris McKee, AMRPA Member ServicesServices Coordinator, at 202-591-2496, cmckee@amrpa.org

AMRPA Magazine / March 2019 39

Team-based Care Transformation in Primary Care Settings May Improve Care of Chronically Ill Patients

Highlight: »»

Team-based approaches to primary care transformation may benefit patients with chronic illness by reducing the use of acute care; however, it may lead to higher use among healthier patients.

A recent study published in JAMA Internal Medicine evaluated the association of team-based primary care with patient health care use and costs. There has been mixed association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions (MCCs). The study authors used difference-indifferences to compare pre-utilization and post-utilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. The authors fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston area between 2011 and 2015. The practices participated in a four-year learning collaborative that created and supported team-based primary care. The data was analyzed between April and August 2018.

// There has been mixed association between teambased primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions (MCCs).

The main outcomes and measures included outpatient visits, hospitalizations, emergency department visits, ambulatory care–sensitive hospitalizations, ambulatory care–sensitive emergency department visits, and total costs of care. The study included 322,408 participants, of which 176,259 (54.7 percent) were female; 64,030 (19.9 percent) were younger than 18 years and 258,378 (80.1 percent) were aged 19 to 64 years. Intervention practices had fewer participants, with 2 or more

40 AMRPA Magazine / March 2019

chronic conditions (n = 51,155 [37.0 percent] vs n = 186,954 [46.6 percent]), more participants younger than 18 years (n = 337,931 [27.5 percent] vs n = 74,691 [18.6 percent]), higher Medicaid enrollment (n = 39,541 [28.6 percent] vs n = 81,417 [20.3 percent]), and similar sex distributions (75,023 women [54.4 percent] vs 220,097 women [54.8 percent]); however, after inverse probability weighting, observable patient characteristics were found to be well balanced. Intervention practices had higher utilization in the pre-period. Patients in intervention practices experienced a 7.4 percent increase in annual outpatient visits relative to baseline (95 percent CI, 3.5 percent-11.3 percent; P < .001) after adjusting for patient age, sex, comorbidity, ZIP code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with two or more chronic conditions, there was a statistically significant 18.6 percent reduction in hospitalizations (95 percent CI, 1.5 percent-33.0 percent; P = .03), 25.2 percent reduction in emergency department visits (95 percent CI, 6.6 percent-44.0 percent; P = .007), and a 36.7 percent reduction in ambulatory care–sensitive emergency department visits (95 percent CI, 9.2 percent-64.0 percent; P = .009). Among patients with less than two comorbidities, there was an increase in outpatient visits (9.2 percent; 95 percent CI, 5.10 percent-13.10 percent; P < .001), hospitalizations (36.2 percent; 95 percent CI, 12.2-566.6; P = .003), and ambulatory care–sensitive hospitalizations (50.6 percent; 95 percent CI, 7.1 percent-329.2 percent; P = .02).

The study found that, among chronically ill patients in 18 practices who were exposed to team-based care, there was an 18 percent reduction in hospitalizations, a 25 percent reduction in emergency department visits, and a 36 percent reduction in ambulatory care–sensitive emergency department visits relative to 76 comparison practices. Among healthier patients, there was an increase in outpatient visits and hospitalizations. The study concluded that while establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it noted that it could lead to greater use among healthier patients. For the study see, Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients, January 2019, JAMA Internal Medicine 2019;179(1):54-61.

AMRPA Magazine / March 2019 41

A M E R I C A N M E D I C A L R E H A B I L I T AT I O N P R O V I D E R S A S S O C I AT I O N

Announcing The AMRPA QRP Certification Program A New Era for Rehabilitation has Begun! Starting October 1, 2019, CMS is eliminating FIM from the IRF-PAI and introducing CMGs based on the GG-H QRP questions. AMRPA is working on key aspects of this change, from policy review and critique to helping hospitals adjust their day-to-day operations. As part of this work, AMRPA is happy to announce the AMRPA QRP Certification Program. Available in early 2019, this system will allow AMRPA member hospitals, as well as eRehabData® subscribers, to electronically test staff on their expertise of the QRP data elements in the IRF-PAI. The tests will be administered through AMRPA’s own eRehabData® system. Best of all, AMRPA member hospitals and eRehabData® subscribers will have unlimited use of this powerful resource, free of charge. Together, we can make the transition from FIM to GG-H smooth and seamless. To learn more, please visit eRehabData.com

42 AMRPA Magazine / March 2019

AHRQ Analysis Finds Hospital-Acquired Conditions Declined By Nearly 1 Million

Highlight: »»

AHRQ projects that a 20 percent reduction would result in 1.8 million fewer HACs over this period, potentially resulting in 53,000 fewer deaths and saving $19.1 billion in hospital costs.

The Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare and Medicaid Services (CMS) released new data showing that reductions in hospital-acquired conditions (HACs), such as adverse drug events (ADEs) and health care-associated infections (HAIs), helped prevent 20,500 hospital deaths and save $7.7 billion in health care costs from 2014 to 2017. AHRQ’s preliminary analysis estimated that HAIs were reduced by 910,000 from 2014 to 2017. The estimated rate of HAIs dropped 13 percent; from 99 per 1,000 acute care discharges to 86 per 1,000 during the same timeframe (see below).

// AHRQ’s preliminary analysis estimated that HAIs were reduced by 910,000 from 2014 to 2017.

AMRPA Magazine / March 2019 43

AHRQâ&#x20AC;&#x2122;s new report quantifies trends for several HAIs, including ADEs, catheter-associated urinary tract infections (CAUTIs), centralline associated bloodstream infections (CL-ABIs), Clostridioides difficile infections (C-diff), pressure injuries (pressure ulcers), and surgical site infections (SSIs). The report showed that harms decreased in several categories, such as ADEs, which dropped 28 percent from 2014 to 2017, though opportunities for improvement continues to exist in other harm categories, such as pressure ulcers. AHRQ has developed a variety of patient safety tools and resources to reduce HACs. The Hospital Improvement Innovation Networks (HIINs) regularly engages with hospitals, providers and the broader caregiver community to quickly implement evidencebased practices in harm reduction to improve the quality of care for Medicare beneficiaries. The agency further supports evidencebased harm-reduction strategies through the Quality Improvement Network-Quality Improvement Organizations (QIN-QIOs) and the End Stage Renal Disease Network Program.

44 AMRPA Magazine / March 2019

CMS has set a goal of reducing HACs by 20 percent between 2014 and 2019. If achieved, AHRQ projects the 20 percent reduction would result in 1.8 million fewer HACs over this period, potentially resulting in 53,000 fewer deaths and saving $19.1 billion in hospital costs. To view AHRQâ&#x20AC;&#x2122;s report, AHRQ National Scorecard on HospitalAcquired Conditions Updated Baseline Rates and Preliminary Results 2014-2017, January 29, 2019 see AHRQs website.

Study Examines Functional Status 10 Years Post Severe Traumatic Brain Injury

Highlight: »»

Providers serving people with severe TBI may wish to develop ongoing follow-up and care plans lasting through the first decade after injury.

// Many people with TBI transition to a rehabilitation hospital or unit for therapy after their acute hospital stay.

A traumatic brain injury (TBI) is a disruption of normal brain function from an external force, such as a fall or a car accident. Many people with TBI transition to a rehabilitation hospital or unit for therapy after their acute hospital stay. According to a study published in the Journal of Neurotrauma, many individuals with severe TBI may be able to recover and regain consciousness as well as their independence.

Persons with a severe TBI may experience disorders of consciousness, such as a coma or a minimally conscious or vegetative state, during which they are unable to follow simple verbal commands such as “squeeze my hand.” Minimally conscious state and vegetative state may be brief (lasting a few hours or days) or extended (lasting months or indefinitely). These individuals may be unable to follow commands while in the hospital or even after transferring to a rehabilitation center. It has been commonly assumed that individuals with disordered consciousness after TBI would not have a meaningful recovery. However, the researchers examined long-term data from a group of people with severe TBI who were still unable to follow commands when they moved from the hospital to a rehabilitation setting. The researchers wanted to find out how much these individuals recovered in their mobility, self-care and cognitive skills during the first decade after their injuries. Researchers at the TBI Model System Centers in Indiana, Massachusetts, Pennsylvania and Texas, and the Tampa Veterans Administration Polytrauma Rehabilitation Center examined data from the TBIMS National Database of 110 individuals aged 16 years or older who had received inpatient rehabilitation for a TBI, and who were unable to follow commands when they entered rehabilitation. The researchers examined hospital records to find out when each individual regained the ability to follow commands, if at all. These individuals (or their caregivers) were then interviewed by phone at one, two, five and 10 years after injury. During each interview, they were asked how much assistance the individual needed to perform 18 activities, on a scale from 1 (total dependence on another person) to 7 (completely independently). The activities included self-care tasks

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such as bathing, eating and dressing; mobility-related tasks such as walking and climbing stairs; and cognitive tasks concerning memory and comprehension. The researchers found that about 16 percent of the individuals regained the ability to follow commands in the first 28 days after their injury. Another 54 percent regained the ability to follow commands after more than 28 days after injury, but while they were still in the rehabilitation center. The remaining 30 percent of the individuals with TBI either regained the ability to follow commands after leaving rehabilitation, or they never regained this ability during the study period. When the researchers looked at independence reported over the 10-year period, they found that many of these individuals recovered a great deal of independence. By the end of the first year, 56 percent were completely independent with self-care; 23 percent were completely independent with mobility; and 16 percent were completely independent with cognition. By the end of the 10 years, those numbers increased to 72 percent for independent self-care, 70 percent for independent mobility, and 25 percent for independent cognition. When looking at the percentage of the individuals who were totally dependent on another person by the end of the 10 years, only 12 percent were totally dependent for self-care, 14 percent were totally dependent for mobility, and 11 percent were totally dependent for cognition.

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The researchers also found that the individuals who regained their ability to follow commands “early” (within the first 28 days after injury), on average, recovered their independence much faster than the individuals who recovered ability to follow commands “late” (more than 28 days after injury) or not at all. Most of the individuals who recovered command-following ability early had recovered full independence in self-care and mobility and some independent cognition by the end of the first year. By comparison, only about half of the individuals who recovered command-following ability late recovered full independence in self-care by the end of their first year, and only about 12 percent recovered independent mobility and cognition during that time period. However, this group did see additional improvements in following years. The authors concluded that individuals with severe TBI may continue to progress in their recovery for months and years after they finish formal rehabilitation. They recommend that providers serving persons with severe TBI should develop ongoing followup and care plans lasting through the first decade after injury. For the study, see Hammond, F., et al. (2018) Disorders of consciousness due to traumatic brain injury: Functional status ten years post-injury. Journal of Neurotrauma, 2018

Robotic Exoskeletons May Offer Health Benefits for Spinal Cord Injury Patients

Highlights: »»

Robotic exoskeletons may offer several physical and psychosocial health benefits; however, their use may incur risks of falls or other complications.

»»

As robotic exoskeleton technology develops, design enhancements may increase their safety and versatility.

// Robotic exoskeletons are wearable devices that provide hip and knee motion with an external power source, allowing the user to stand upright and walk limited distances.

New research from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) has found that robotic exoskeletons may provide health benefits for persons with spinal cord injuries (SCIs). The findings were published in the National Rehabilitation Information Center (NARIC) Research In Focus.

A spinal cord injury is damage anywhere along the spinal cord from an accident or other trauma. Persons with SCI may have partial or total paralysis, especially in their leg muscles. Robotic exoskeletons are wearable devices that provide hip and knee motion with an external power source, allowing the user to stand upright and walk limited distances. An exoskeleton often consists of a frame surrounding the torso or waist and hinged braces strapped to the legs. It is usually powered by a battery pack, providing several hours of powerassisted movement. Exoskeletons are currently in limited use in rehabilitation hospitals and research centers across the United States.

The researchers wanted to explore the types of settings in which therapists and patients worked with exoskeletons, the perceived benefits and risks of exoskeleton use, and what recommendations the therapists had for improving exoskeleton design. Researchers at the Spinal Cord Injury Model System (SCIMS) Centers in Colorado, Georgia, Illinois and Texas held focus groups with 30 therapists working at four affiliated rehabilitation hospitals. Most of the clinician participants were physical, exercise or recreational therapists, and all had training in the use of robotic exoskeletons with patients with SCI. During the focus groups, the therapists were asked to describe the settings in which they used exoskeletons with their patients and the procedures they followed. The therapists were also asked to describe their observations of what their patients expected from exoskeletons, the benefits they and their patients perceived from exoskeleton use, and the observed or potential risks of exoskeleton use. Finally, the therapists were asked about design enhancements that they would recommend to exoskeleton manufacturers.

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The researchers found that the therapists at all four SCIMS centers used robotic exoskeletons mainly in outpatient and community wellness settings. The therapists reported that patients could learn to use the robotic exoskeleton proficiently in about 20 to 30 sessions, where they practiced standing, stepping and gait training with the aid of one or more therapists or trainers. Regarding benefits and risks of exoskeletons, the therapists reported that many patients found the exoskeletons motivating and exciting. They observed that patients who gained the ability to stand and walk with an exoskeleton often developed better endurance, improved their bowel and bladder control, and were less likely to develop urinary tract infections. The therapists also reported that some patients described psychological benefits from standing eye-to-eye with conversation partners and participating in more activities by regaining the ability to walk. However, the therapists also identified some risks to exoskeleton use including a risk of falling, skin sores from repeated contact with the exoskeleton, or patient disappointment with the limits of the technology. Finally, the therapists suggested some design enhancements to make the exoskeletons safer and more user-friendly. These

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included reducing the weight and bulk of the exoskeletons, adding greater adjustability, improving durability, adding onehanded controls, optimizing the exoskeletons for use on stairs or uneven terrain, and allowing the user to balance without arm support. The authors found that robotic exoskeletons may be highly motivating for people with SCI, and they may offer several physical and psychosocial health benefits. However, these exoskeletons may not always meet patientsâ&#x20AC;&#x2122; expectations, and their use may incur risks of falls or other complications. As robotic exoskeleton technology develops, design enhancements may increase their safety and versatility. The authors also noted that therapists may benefit from more standardized training and guidance on the optimal use of exoskeletons in SCI rehabilitation. Future research would be useful in examining the strengths and limitations of robotic exoskeletons as the technology evolves over time. To learn more about the study see Heinemann, A.W. et al. (2018) Experience of robotic exoskeleton use at four spinal cord injury model systems centers. Journal of Neurologic Physical Therapy, 42(4), 256-267.

Latest Research Findings

Electronic Patient Portal Use Following Total Joint Arthroplasty Does Not Decrease Readmissions As reimbursement models evolve, there is an increasing effort to decrease 90-day hospital resource utilization and patient readmissions, and secure messaging portals have been proposed as one way to achieve this goal. A recent article in the Journal of Arthroplasty sought to determine which patients utilize an electronic messaging portal, and to determine the impact of secure messaging on emergency department (ED) visits and readmissions within 90 days postoperatively. The messaging portal (MyChart) allows patients to communicate directly with their health care provider. The institutional database used to analyze 6,426 procedures included 3,297 primary total knee and 3,129 primary total hip arthroplasties. Patient demographics, comorbidities and secure communication activity status were recorded. Statistical analysis was performed to determine which patients utilized MyChart, as well as to correlate patient outcomes to the utilization of secure messaging portals.

The study found that primary total joint arthroplasty patients who were at high risk for ED returns were less likely to utilize MyChart. However, MyChart use did not decrease the 90-day rate of return to the ED or readmissions. A low provider response rate to the secure messages may lead to increased resource utilization in patients using secure messaging as their preferred communication tool. Alternative means of communication with the most vulnerable patients must be investigated to effectively decrease postoperative complications and resource utilization. For the study see, Utilization of an Electronic Patient Portal Following Total Joint Arthroplasty Does Not Decrease Readmissions, the Journal of Arthroplasty, Volume 34, Issue 2, February 2019, Pages 211-214.

The article noted that active MyChart users were significantly more likely to be young, healthy, Caucasian, married, employed, have private insurance and be discharged to home. Decreased utilization was seen in patients who were unhealthy, were African American, unmarried, unemployed, had Medicare or Medicaid insurance and were discharged to a skilled nursing facility. These characteristics were also independent significant risks for returning to the ED. Active MyChart status was not significantly associated with 90-day ED return (P = .781) or readmission (P = .512). However, if multiple messages to providers were sent, and the provider response rate was <75 percent, patients had significantly more readmissions (P = .004).

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Massage May Provide Short-term Improvement of Knee Osteoarthritis Symptoms According to a new study published in the Journal of General Internal Medicine, a weekly session of massage therapy may provide short-term benefits for persons with osteoarthritis of the knee, including reduced pain and stiffness and improved function. The National Center for Complementary and Integrative Health (NCCIH)-funded study was done at locations in North Carolina, New Jersey, and Connecticut. Researchers randomly assigned 222 people with knee osteoarthritis to receive whole-body Swedish massage, light touch or usual care. Light touch involved the massage therapist gently placing his or her hands in a specified sequence on the participantâ&#x20AC;&#x2122;s major muscle groups and joints. Usual care was the participantâ&#x20AC;&#x2122;s typical care regimen for osteoarthritis. Participants in the massage or light touch groups received eight weekly treatments (lasting 60 minutes each), and then were randomly assigned to receive treatment every two weeks or usual care to week 52. The researchers found that eight weeks of massage provided statistically and clinically significant improvement of osteoarthritis symptoms, as assessed by a widely used questionnaire that evaluates the condition of people with arthritis. Pain, stiffness and physical function all improved. The researchers noted that these findings helped demonstrate the safety, feasibility and potential efficacy of eight weeks of massage therapy in improving pain, stiffness, timed 50-foot walk, and physical function compared to a waitlist control. However, long-term benefits were less clear; after eight weeks of treatment, massage therapy maintained improvement but did not provide

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additional benefit beyond usual care. The researchers noted that the study size was relatively small, and the participants were mostly white women. The results may not be generalizable to other groups of people. For the study see, Perlman A, Fogerite SG, Glass O, et al. Efficacy and safety of massage for osteoarthritis of the knee: a randomized clinical trial. Journal of General Internal Medicine. December 12, 2018.

AMRPA Congressional News Center Key Committee Assignments The 116th Congress was sworn in on January, 3 2019. There have been some notable changes to key the Congressional Committees that have oversight over Medicare and other important health care issues. Below you will find Congressional committee assignments relevant to medical rehabilitation. House Ways & Means Committee Chair: Rep. Richie Neal (D-MA-1) Ranking Member: Rep. Kevin Brady (D-TX-8) Health Subcommittee Chair: Rep. Lloyd Doggett (D-TX-35) Health Subcommittee Ranking Member: Rep. Devin Nunes (R-CA-22) Rep. Jodey Arrington (R-TX-19) Rep. John Larson (D-CT-1) Rep. Don Beyer (D-VA-8)* Rep. John Lewis (D-GA-5) Rep. Earl Blumenauer (D-OR-3) Rep. Kenny Marchant (R-TX-24) Rep. Brendan Boyle (D-PA-2)* Rep. Gwen Moore (D-WI-4)* Rep. Vern Buchanan (R-FL-16) Rep. Stephanie Murphy (D-FL-7)* Rep. Judy Chu (D-CA-27) Rep. Jimmy Panetta (D-CA-20)* Rep. Danny Davis (D-IL-7)

Rep. Bill Pascrell (D-NJ-9) Rep. Suzan DelBene (D-WA-1) Rep. Tom Reed (R-NY-23) Rep. Ron Estes (R-KS-4) Rep. Tom Rice (R-SC-7) Rep. Dwight Evans (D-PA-3)* Rep. Linda Sanchez (D-CA-38) Rep. Drew Ferguson (R-GA-3) Rep. Brad Schneider (D-IL-10)* Rep. Jimmy Gomez (D-CA-34) Rep. David Schweikert (R-AZ-6) Rep. Brian Higgins (D-NY-26) Rep. Terri Sewell (D-AL-7)

Rep. George Holding (R-NC-2) Rep. Adrian Smith (R-NE-3) Rep. Steven Horsford (D-NV-4)* Rep. Jason Smith (R-MO-8) Rep. Mike Kelly (R-PA-16) Rep. Tom Suozzi (D-NY-3)* Rep. Dan Kildee (D-MI-5)* Rep. Mike Thompson (D-CA-5) Rep. Ron Kind (D-WI-3) Rep. Jackie Walorski (R-IN-2) Rep. Darin LaHood (R-IL-18) Rep. Brad Wenstrup (R-OH-2)

Rep. Kathy Castor (D-FL-14) Rep. Markwayne Mullin (R-OK-2) Rep. Yvette Clarke (D-NY-9) Rep. Tom O’Halleran (D-AZ-1)* Rep. Diana DeGette (D-CO-01) Rep. Pete Olson (R-TX-22) Rep. Debbie Dingell (D-MI-12) Rep. Scott Peters (D-CA-52) Rep. Michael Doyle (D-PA-18) Rep. Raul Ruiz (D-CA-36) Rep. Jeff Duncan (R-SC-3) Rep. Bobby Rush (D-IL-1) Rep. Eliot Engel (D-NY-16) Rep. John Sarbanes (D-MD-3) Rep. Anna Eshoo (D-CA-18) Rep. Steve Scalise (R-LA-1) Rep. Bill Flores (R-TX-17) Rep. Janice Schakowsky (D-IL-09)

Rep. Greg Gianforte (R-MT-At-Large) Rep. Kurt Schrader (D-OR-5) Rep. H. Griffith (R-VA-9) Rep. John Shimkus (R-IL-15) Rep. Brett Guthrie (R-KY-2) Rep. Darren Soto (D-FL-9)* Rep. Richard Hudson (R-NC-8) Rep. Paul Tonko (D-NY-20) Rep. Bill Johnson (R-OH-6) Rep. Fred Upton (R-MI-6) Rep. Robin Kelly (D-IL-2)* Rep. Marc Veasey (D-TX-33)* Rep. Joseph Kennedy (D-MA-4) Rep. Tim Walberg (R-MI-7) Rep. Adam Kinzinger (R-IL-16) Rep. Peter Welch (D-VT-At-Large) Rep. Robert Latta (R-OH-5)

House Energy & Commerce Committee Chair: Frank Pallone (D-NJ-6) Ranking Member: Greg Walden (R-OR-2) Rep. Nanette Barragan (D-CA-44)* Rep. David Loebsack (D-IA-2) Rep. Gus Bilirakis (R-FL-12) Rep. Billy Long (R-MO-7) Rep. Lisa Blunt Rochester (D-DE-At-Large)* Rep. Ben Luján (D-NM-3) Rep. Susan Brooks (R-IN-5) Rep. Doris Matsui (D-CA-06) Rep. Larry Bucshon (R-IN-8) Rep. Don McEachin (D-VA-4)* Rep. Michael Burgess (R-TX-26) Rep. David McKinley (R-WV-1) Rep. G. K. Butterfield (D-NC-1) Rep. Ann McLane Kuster (D-N-2)* Rep. Tony Cárdenas (D-CA-29) Rep. Cathy McMorris Rodgers (R-WA-5) Rep. Earl Carter (R-GA-1) Rep. Jerry McNerney (D-CA-9)

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Senate Finance Committee Chair: Sen. Chuck Grassley (R-IA) Ranking Member: Sen. Ron Wyden (D-OR) Sen. Michael Bennet (D-CO) Sen. Maggie Hassan (D-NH) Sen. Sherrod Brown (D-OH) Sen. Johnny Isakson (R-GA) Sen. Richard Burr (R-NC) Sen. James Lankford (R-OK) Sen. Maria Cantwell (D-WA) Sen. Bob Menendez (D-NJ) Sen. Ben Cardin (D-MD)

Sen. Rob Portman (R-OH) Sen. Tom Carper (D-DE) Sen. Pat Roberts (R-KS) Sen. Bob Casey (D-PA) Sen. Debbie Stabenow (D-MI) Sen. Bill Cassidy (R-LA) Sen. Tim Scott (R-SC) Sen. John Cornyn (R-TX) Sen. John Thune (R-SD)

Sen. Catherine Cortez Masto (D-NV) Sen. Pat Toomey (R-PA) Sen. Mike Crapo (R-ID) Sen. Mark Warner (D-VA) Sen. Steve Daines (R-MT) Sen. Sheldon Whitehouse (D-RI) Sen. Mike Enzi (R-WY) Sen. Todd Young - Indiana

Sen. Bill Cassidy (R-LA) Sen. Mitt Romney (R-UT)* Sen. Susan Collins (R-ME) Sen. Jacky Rosen (D-NV)* Sen. Mike Enzi (R-WY) Sen. Bernie Sanders (I-VT) Sen. Maggie Hassan (D-NH) Sen. Tim Scott (R-SC)

Sen. Johnny Isakson (R-GA) Sen. Tina Smith (D-MN) Sen. Doug Jones (D-AL) Sen. Elizabeth Warren (D-MA) Sen. Tim Kaine (D-VA)

Senate HELP Committee Chair: Sen. Lamar Alexander (R-TN) Ranking Member: Sen. Patty Murray (D-WA) Sen. Tammy Baldwin (D-WI) Sen. Lisa Murkowski (R-AK) Sen. Mike Braun (R-IN)* Sen. Chris Murphy (D-CT) Sen. Richard Burr (R-NC) Sen. Rand Paul (R-KY) Sen. Bob Casey (D-PA) Sen. Pat Roberts (R-KS) * New addition to the committee If you haven’t done so already, reach out to your newly or re-elected Congressional representatives and educate them about the value of care provided in inpatient rehabilitation hospitals and units by offering them a tour of your hospital, meeting with them at their offices, or visiting with them during town hall or community meetings. You may follow these steps to set up a meeting with your Congressional Representatives: • Call the U.S. Capitol Switchboard at (202) 224-3121 and ask for your Senators’ and Representative's office or access their contact information online at www.house.gov and www.senate.gov. • Ask the office for instructions regarding the preferred way to submit a request for a meeting or an invitation to tour your hospital or unit in the District/State. Congressional offices handle their District scheduling requests differently. The Washington, D.C. office may arrange for the meeting directly or may refer you to their Congressional District office to set up the visit. • Once you have a meeting or tour scheduled, please inform Kendall Hussey (khussey@akingump.com / 202-416-5207) so we can track AMRPA’s outreach efforts. We encourage members to also check the Congressional News Center webpage for more up-to-date information: https://amrpa.org/ Advocacy-News/Congressional-Affairs/Congressional-News-Center. If you have any questions or feedback, contact Catherine Beal at cbeal@amrpa.org or (202) 860-1006.

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AMRPA & eRehabDataÂŽ Have Your Back

We adapt to regulatory updates to provide real time outcomes reports to inpatient rehabilitation hospitals and units.

Visit eRehabData.com to learn more, or contact Sam Fleming at sam@erehabdata.com to receive a free demo. Without losing any historical data, our staff help you migrate to the only patient assessment system that is trusted, owned, used, and supported by the medical rehabilitation industry. 56 AMRPA Magazine / March 2019