AMRPA Magazine May 2018

May 2018 • Vol. 21, No. 5

SPEAKING WITH

VOICE AMRPA’s Spring Leadership Conference and Congressional Fly-In

April 2018 • Vol. 21, No. 5

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

AMRPA Magazine, Volume 21, Number 5 AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA).

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

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Table of Contents Letter from the Chair

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AMRPA Legislative Update

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Important Developments with the ALJ Backlog of Medicare Appeals

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Selecting the Etiologic Diagnosis

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MedPAC’s Annual March Report to Congress Includes FY 2019 Payment Recommendation for Inpatient Rehabilitation Hospitals/Units and Other Updates

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Draft IMPACT Transfer of Health Information Measures Shift Focus to Medication Information

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HHS OIG Finds High Rate of Claims Errors in Review of Medicare Outpatient Therapy Services

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AMRPA Holds Successful 2018 Spring Conference and Congressional Fly-In

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2018 Final Health Insurance Exchanges Enrollment Report Released

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CMS Oversight of Medicare Beneficiary Data Security Needs Improvement, GAO Says

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NCHS Report Finds Differences Among Adult Day Service Centers, by Ownership

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Latest Research Findings

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Medicare Discharges to SNFs Are Declining, Avalere Says

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CMS Releases 2015 Medicare Current Beneficiary Survey Chartbook

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MACPAC’s 2018 Report Outlines Ways to Improve Efficiencies in the Medicaid and CHIP Program

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AMRPA Submits Comments to Congress on Increasing Consumer Transparency in Medicare Advantage Plans

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Federal Elections Center

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Letter from the Chair

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

Speaking with One Voice

AMRPA’s Spring Leadership Conference and Congressional Fly-In In March, AMRPA held its Annual Spring Leadership Conference and Congressional Fly-in. Our leading policy conference occurred in combination with our annual Medical Directors’ Symposium and Rehabilitation Administrators’ Workshop.

Combined we had more than 140 attendees at the conference. The registrants were varied from medical directors and other health care professionals to unit directors, chief executives and operating officers. We had representatives from freestanding rehabilitation hospitals, rehabilitation units of acute care hospitals, for-profit and not-for-profit hospitals. Needless to say, there was a rich sharing of ideas.

The attendees heard directly from representatives of CMS on such topics as provider compliance, Comprehensive Error Rate Testing, payment policy for postacute care, and the Inpatient Rehabilitation Facility Quality Reporting Program.

A panel of CMS staff led a discussion focused on standardizing post-acute care assessment data and quality measures as mandated by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. We also heard from congressional staff representing the House Ways and Means Committee and Senate Leadership staff. We were honored to have an administration official from the Office of Management and Budget address the President’s 2019 budget.

In addition, attendees appreciated the perspective provided by the executive director of the Medicare Payment and Advisory Commission and the secretary of the U.S. Department of Veterans Affairs. Many of us then took our stories from the field directly to Capitol Hill.

These events collectively provided our field with the opportunity to share our views with and to hear directly from federal agency officials and Washington influencers. An article in this issue of the magazine provides a detailed overview of the Spring Conference and highlights key discussion points from our speakers.

// These events collectively provided our field with the opportunity to share our views with and to hear directly from federal agency officials and Washington influencers.

AMRPA’s current work was also discussed. There were association staff presentations from Carolyn Zollar, AMRPA’s executive vice president for governmental relations and policy development, Martie Kendrick, who serves as our outside Washington counsel from Akin Gump, and Sam Fleming of AMRPA’s eRehabData®. These presentations conveyed an important portrayal of our efforts.

Each speaker at the conference provided attendees with great insights into regulatory and legislative activities affecting our industry and our patients. Many presenters highlighted how AMRPA is supporting our efforts in the field to ensure that our patients have access to care they need. These discussions permitted the

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association to then identify our regulatory and legislative priorities. The priorities include but are not limited to:

Medicare Advantage Accountability; Reform the Medicare Audit, Denials and Appeals Process; Reform the 60 Percent and Three-Hour Rules; Front-End Deficit Reduction/Back-End Payment Reform; Discharge Planning Transparency; Unified Post-Acute Care Prospective Payment System as proposed by MedPAC; Value-Based Purchasing models proposed in recent sessions of Congress; Implementation of the Congressionally mandated Continuing Care Hospital; and Quality measures.

We are actively working to identify potential strategic approaches to address each of these priorities in 2018.

In addition to the wonderful platform of speakers we were able to honor two individuals with our 2018 Chairman’s Award.

We honored Dale Eazell who was a founding member of the association’s board and was the board’s first chair. We also recognized Judith Stein for her work in support of medical

rehabilitation. Stein is the executive director of the Center for Medicare Advocacy, which she founded in 1986. The Center advocates on behalf of Medicare beneficiaries and strives to advance access to comprehensive coverage for older people and people with disabilities.

Attendees reported the time spent in Washington to be productive and insightful. This event provided a unique opportunity to network and share our individual and Association messages with our colleagues and to those making policy decisions affecting our patients. We continue to need your direct voice and participation in our advocacy work so please plan to attend the annual spring conference next year. We also hope to see you at our Fall Educational Conference & Expo in Boston (September 24-26) where we can again speak with one voice and find new opportunities to ensure patient access to inpatient rehabilitation hospitals and units. The fall conference will concentrate on operations and clinical management issues as well as opportunities to hear the latest research from our field.

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Legislative Update

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

Highlights: »»

On March 23, President Trump reluctantly signed the FY 2018 Consolidated Appropriations Act into law, finalizing the 2018 Appropriations process.

»»

On March 28, President Trump tweeted thanks to Veterans Affairs Secretary Shulkin for his service, and announced the appointment of Rear Admiral Ronny Jackson, the president’s personal physician, as his choice for the new VA Secretary.

»»

he Medicare Payment T Advisory Commission (MedPAC) recommends reducing the FY 2019 Medicare payment rate for inpatient rehabilitation facilities by 5 percent, among other postacute care policies, in its annual March Report to Congress.

»»

MS finalized an increase of 3.4 C percent in payments to Medicare Advantage plans in 2019.

FY 2018 Appropriations Process Finally Crosses Finish Line After four short-term Continuing Resolutions (CR) to fund the federal government, President Trump on March 23 signed into law the Fiscal Year (FY) 2018 Consolidated Appropriations Act, even while expressing dissatisfaction with the bill’s cost and lack of border wall funding. The $1.3 trillion Omnibus spending package did not include Affordable Care Act (ACA) market stabilization legislation and did not address the Deferred Action for Childhood Arrivals (DACA) initiative. Among its many provisions, the bill includes nearly $4 billion in opioid response funding, $37 billion for the National Institutes of Health (NIH), a $3 billion increase from the previous year, and report language directing the Department of Veterans Affairs (VA) to take additional actions to ensure prompt payment to providers.

FY 2019 Appropriations Process Begins Congressional hearings are already underway to consider FY 2019 funding. The House Appropriations Committee’s Labor-HHS-Education Subcommittee will hold a “Member’s Day” hearing and a public witnesses hearing in April, along with another hearing on the National Institutes of Health (NIH) Budget. Lawmakers are likely to rely on another Omnibus spending bill or a short-term CR to fund the government past September 30, 2018, as has been the historical method for keeping the government open and operational. With election year politics becoming an increasingly potent factor in legislative decision-making, it is possible – if not predictable – that any CR would fund the federal government past Election Day and into the Lame Duck session of the 115th Congress.

Opioid Epidemic Remains Priority for Congressional and Executive Action Both the White House and Congress are stepping up their efforts to combat the opioid crisis. On March 19, President Trump and Health and Human Services (HHS) Secretary Alex Azar traveled to New Hampshire and announced a new “Initiative to Stop Opioids Abuse and Reduce Drug Supply and Demand.” Among other measures, the plan calls for reducing opioid prescriptions by one-third within three years; the launch of a public awareness campaign about the dangers of drug use; and elimination of the Institution for Mental Disease (IMD) exclusion. On April 4, NIH announced it is launching the Helping to End Addiction Long-term (HEAL) Initiative to accelerate scientific solutions for the opioid crisis. Using recent funding appropriated through the Omnibus, NIH will bolster research into pain management and addiction treatment, as part of the HEAL. Meanwhile, the House Energy and Commerce Committee planned to hold its third and possibly final legislative hearing on the opioid crisis on April 11, examining more than a dozen bills related to coverage and payment issues. Chair Greg Walden (R-OR) indicated his desire to bring comprehensive opioid legislation to

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the House floor before Memorial Day. The Senate Health, Education, Labor and Pensions (HELP) Committee also announced a hearing on April 11 to discuss draft legislation it released on April 4. The draft encourages the use of telemedicine to treat patients and register them with the Drug Enforcement Administration (DEA) if prescribed pain medication, as well as encourages states to share drug monitoring program data and addresses issues with appropriate disclosure of private substance abuse records with providers.

MedPAC Releases Annual March Report to Congress On March 15, the Medicare Payment Advisory Commission (MedPAC) released its March 2018 Report to the Congress.

MedPAC recommends eliminating the Merit-based Incentive Payment System (MIPS) established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and moving to a new voluntary value-based payment system for clinicians. The report also reviews telehealth services and Medicare coverage of these services. Specific to inpatient rehabilitation providers, the commissioners finalized the following recommendations which are unchanged from the draft recommendations AMRPA reported to the membership in January.

Recommendation from Chapter 7 Post-acute care: Increasing the equity of Medicare’s payments within each setting: The Congress should direct the Secretary to begin to base Medicare payments to post-acute care (PAC) providers on a blend of each sector’s setting-specific relative weights and the unified PAC prospective payment system’s relative weights in fiscal year 2019.

Recommendation from Chapter 10: Inpatient rehabilitation facilities: The Congress should reduce the fiscal year 2019 Medicare payment rate for inpatient rehabilitation facilities by 5 percent.

Additionally, the commission reiterates its March 2016 recommendations on the IRF PPS, which are as follows: The Secretary should conduct focused medical record review of inpatient rehabilitation facilities that have unusual patterns of case mix and coding.

The Secretary should expand the inpatient rehabilitation facility outlier pool to redistribute payments more equitably across cases and providers.

Secretary Shulkin Out as Head of Veterans Affairs Department The departure of former VA Secretary Shulkin has raised questions about the outlook for action on VA health reform and reauthorization of the Veterans Choice Program. The change in leadership at the VA is believed to reflect a stronger push from the Trump administration to expand veterans' access to community-based care in the private sector, although the White House has stated that it is not seeking to “privatize” the VA’s health care system. Former Secretary

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Shulkin recently indicated in testimony that funding for the Veterans Choice Program will run out in late May or June.

President Trump announced the appointment of Rear Admiral Ronny Jackson, the president’s personal physician, as his choice for the new VA Secretary.

Adam Boehler Named as New Director of CMA Innovation Center After months of speculation, on April 6, Health and Human Services (HHS) Secretary Alex Azar announced that Adam Boehler will lead the Center for Medicare and Medicaid Innovation. Boehler is the former CEO and founder of Landmark Health, a company that provides urgent care visits in the home. In order to circumvent any conflicts of interest, he had to sell his stake in the company before officially taking the helm of the Innovation Center. The administration previously delayed his appointment for several months because of the potential conflicts situation. The Innovation Center was created under the Affordable Care Act and has been a driver in testing innovative, and sometimes controversial, health care payment and delivery models. A few programs have been rolled back under Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma, including the expansion of mandatory bundled payment models.

CMS Final Rule Increases Medicare Advantage Flexibility On April 6, the Centers for Medicare and Medicaid Services (CMS) released a final rule on Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program.

This final rule revises Medicare Advantage (MA) and Part D regulations to implement provisions of the Comprehensive Addiction and Recovery Act; implement provisions of the 21st Century Cures Act; improve program quality, accessibility, and affordability; improve the CMS customer experience; address program integrity policies; provide an update on Part D electronic prescribing standards; and clarify program requirements regarding treatment of Part A and B appeal rights related to premiums adjustments. The updated policy will potentially allow MA plans to offer non-medical care related benefits, including transportation or meal delivery, and eliminates the “meaningful difference” requirement for MA plans, in order to increase the number of plan options for Medicare beneficiaries.

Medicare Advantage and Part D Changes Finalized On April 2, CMS finalized a number of changes to MA and Part D policies in its 2019 Rate Announcement and Call Letter and a final rule on Calendar Year (CY) 2019 policy and technical changes to MA and Part D. CMS estimates MA plan revenues will increase 3.4 percent in 2019, not including a 3.1 percent adjustment from coding changes. The Call Letter also includes changes to allow MA plans to offer additional supplemental benefits. Both the Call Letter and final rule include policies to reduce opioid abuse and misuse among Part D beneficiaries. Of note, CMS finalized a new authority that permits Part D sponsors to require beneficiaries at risk

of addiction or overuse to use only selected prescribers or pharmacies for opioid prescriptions.

CMS Proposed Rule on Medicaid Access to Care Requirements On March 22, CMS released a proposed rule to ease some access-to-care reporting requirements for state Medicaid programs. Specifically, the rule would exempt states (currently 17 states) with a Medicaid managed care penetration rate of at least 85 percent from most access monitoring requirements, and provide similar flexibilities for states that make small rate reductions. This initiative is part of a series of regulatory relief proposals stemming from the president’s desire to “cut the red tape” and the CMS administrator’s priority to empower state innovation in Medicaid programs.

HHS Notice of 2019 Benefit and Payment Parameters On April 9, HHS released the Notice of Benefit and Payment Parameters for 2019 Final Rule, which sets forth CMS standards for issuers and Exchanges for plan years beginning January 1, 2019. The rule finalizes a number of changes intended to promote state flexibility and consumer choice, including offering states more options for selecting their essential health benefit (EHB) benchmark plan and allowing issuers to substitute benefits across EHB categories. CMS will continue to defer to state reviews of network adequacy for the Exchanges. The rule also eliminates the requirement that issuers offer plans that are “meaningfully” different from each other.

in two areas of potential interest to AMRPA members: preventing health care-associated infections (HAI) and efforts for combating antibiotic-resistant bacteria (CARB). AHRQ’s HAI program funds aim to assist frontline clinicians and other health care staff prevent HAIs by improving care delivery.

AHRQ stated that the HAI research projects should advance the knowledge of HAI detection, prevention and reduction of HAIs. The CARB research project is focused on ways to promote appropriate antibiotic use, reduce the transmission of resistant bacteria or prevent HAIs. Researchers who focus on health care settings including long-term care, ambulatory care, acute care hospitals and transitions between care settings are eligible to apply. Further details can be found at grants.gov.

Although Congress seems acutely focused on moving proposals to address the opioid epidemic, the House Ways and Means Subcommittee Chair Peter Roskam (R-IL) continues to move forward with a regulatory relief initiative aimed at helping Medicare providers. AMRPA will be working closely with the committee and other members of Congress to relay its policy priorities, but we need your help and insights. We would appreciate you reaching out to your elected officials to let them know how access to IRFs is being threatened by MA plans improperly denying patients admittance and the arcane, burdensome policies that are making it difficult for patients to obtain medically necessary IRF care. We are here to help in any way you need and AMRPA thanks you in advance for advocating on behalf of the field and the patients we serve.

AHRQ Announces Funding Available for Prevention of HAIs The Agency for Healthcare Research and Quality (AHRQ) is promoting funding available for large research projects

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Important Developments with the ALJ Backlog of Medicare Appeals

Peter W. Thomas, Counsel to the AMRPA Denials Management Committee and the Consumer and Clinical Affairs Committee

Recent weeks have witnessed significant developments toward the goal of reducing the lengthy backlog of Medicare appeals awaiting hearings and decisions by the administrative law judges (ALJs) who work under the Office of Medicare Hearings and Appeals (OMHA). A hearing in the American Hospital Association v. HHS Secretary Azar litigation occurred, culminating in a discussion about resolution of the ALJ backlog that had been thoroughly briefed over the course of the past several months. Congress finally appropriated the remainder of funding for fiscal year 2018 for the OMHA, which produced a huge increase of resources available to hire more ALJ teams, which could prove to be a double-edged sword. Finally, experience with newly appointed ALJs suggests that OMHA has a long way to go in terms of standardized hearing processes, which can vary significantly from one ALJ to the next.

AHA v. Azar Hearing A federal district court hearing was held on March 22 in the ALJ delay case, AHA v. Azar. The judge decided to impose a “stay” in the case for 90 days until June 22, 2018. By that date, the judge ordered AHA to submit specific proposals for the court to consider imposing in a mandamus order. HHS will have until July 6, 2018, to respond and also to inform the court of the status of HHS’s current efforts to reduce the backlog. AHA may file a reply by July 13, 2018.

Christina A Hughes, J.D., MPH, Counsel, Powers Law Firm

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The judge stated that he is hesitant to re-impose time deadlines to reduce the backlog. This was the remedy the judge previously imposed on the government, but the Circuit Court for the District of Columbia reversed that decision and sent

the case back to the district court for the March 22 hearing in order to consider other alternatives. Instead of time deadlines, the judge stated that he would like to consider concrete steps that HHS could take to reduce the backlog.

AHA emphasized that it has proposed several measures that HHS has rejected in previous hearings earlier in the case, such as further Recovery Audit Contractor (RAC) reforms, additional settlements, and foregoing recoupment until an ALJ decision is issued. HHS pointed out that it has already instituted several reforms to the auditing and administrative appeals processes. For instance, in the latest “Statement of Work” between the Centers for Medicare and Medicaid Services (CMS) and the RACs, it placed greater limitations on auditing processes of these contractors.

It has also implemented the Settlement Facilitation Conference and the low volume settlement initiative.

The judge proposed tolling—or delaying—recoupment until the ALJ decision is made while permitting interest to accrue. He felt that this would reduce some of the harm of the ALJ delay by permitting providers to keep the funds, while building in a financial incentive for providers to pursue only strong cases. Neither side was in favor of this, although it should be noted that AMRPA and the FAIR Fund have endorsed this proposal in the past. In the end, the judge did not impose this but may do so after the additional briefing has concluded. Instead, the judge decided that more time is needed to see whether HHS’s current initiatives are having an effect while giving AHA another opportunity to propose remedies.

The IRF settlement discussions were mentioned by both parties. AHA pointed to it as an example of HHS’s unwillingness to settle. HHS responded that the IRF offer of 80 percent was “unreasonable” and asserted it is under no obligation to accept unreasonable settlement offers. HHS also asserted that it made a counter offer in the IRF settlement discussions but the parties are still in negotiations. The 90-day stay in the AHA v. Azar case may be an opportunity for the rehabilitation field as a successful settlement with IRFs in the interim would be a positive example for HHS to take to the court and argue that additional proposals are unnecessary.

Funding for ALJs Dramatically Increased On March 23, 2018, the president signed a massive omnibus spending bill to fund the federal government through the remainder of fiscal year 2018, which ends on September 30. With billions in discretionary spending available to appropriators, Congress granted the OMHA a massive budget increase of approximately $75 million, over and above its existing funding level of $107 million. This means that OMHA will be have an overall budget for the current fiscal year of $182 million. This will facilitate the hiring of numerous ALJs and support staff, which should lead to far more appeals being processed in a more timely manner than in recent years.

// This development appears to be a double-edged sword.

A major increase in ALJ teams will allow OMHA to hold more hearings and render quicker decisions, eventually alleviating the ALJ backlog to some extent. While this would be welcome news to Medicare providers, there is a strong likelihood that RACs and other Medicare contractors will view this as an opportunity to review and more frequently deny Medicare claims...

A similarly massive budget increase for OMHA was proposed by the Trump administration for FY 2018, $251 million, but $125 million of the increase was intended to be taken out of the Medicare Trust Fund in the form of mandatory spending. Congress did not choose to pursue this approach but, instead, took the funding out of discretionary funds, which must be appropriated each year through the routine appropriations process. Report language from the bill imposes additional requirements on OMHA that signals congressional intent to more closely monitor the status of the ALJ backlog. It states: Office of Medicare Hearings and Appeals The agreement directs the Office of Medicare Hearings and Appeals to provide quarterly reports to the Committees on Appropriations of the House of Representatives and the Senate reflecting the total number of appeals filed, appeals pending, and appeals disposed of for all levels of the appeals process.

The quarterly updates should include a breakout of Recovery Audit Contractor (RAC) and non-RAC claims.

This development appears to be a double-edged sword.

A major increase in ALJ teams will allow OMHA to hold more hearings and render quicker decisions, eventually alleviating the ALJ backlog to some extent. While this would be welcome news to Medicare providers, there

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is a strong likelihood that RACs and other Medicare contractors will view this as an opportunity to review and more frequently deny Medicare claims, confident that the backlog issue will slowly lose its strength. It is incumbent upon the IRF community and other providers to continue to press CMS to restrain their audit contractors until CMS can guarantee that hearings are held and decisions are made within 90 days, as the Medicare statute requires.

New ALJs Bring Inconsistencies in Hearing Processes OMHA has taken some steps to reduce the backlog of appeals awaiting ALJ hearings in the past months. New settlement options and revisions to existing initiatives have been announced, and a group of new ALJs have been hired.

With the assistance of these new ALJs, OMHA is currently scheduling appeals filed in 2013 and early 2014 for hearing.

Many inpatient rehabilitation hospitals and units (IRH/Us) have appeals filed within this time period, mostly related to the activities of the recovery audit contractors (RACs).

As IRH/Us encounter the new ALJs, a few observations can be made. First, the new ALJs are surprisingly similar to the existing ALJs. The reason for the surprise is grounded in CMS’ continued assertions that the ALJs are operating too independently and disregarding CMS coverage policies too freely. According to CMS, this results in appeal decisions that too frequently overturn the denials issued at lower levels. CMS worked to curtail some of the ALJs’ discretion in its revision of the appeal regulations that became effective on March 20, 2017. Specifically, the regulations now require the ALJs to explain any deviations from available manual guidance or other agency guidance, even though such guidance is not binding on the ALJs. Given CMS’ professed goal to “educate” new personnel coming in to serve as ALJs and the new restrictions on ALJs’ discretion, it is surprising to encounter so many new ALJs who already appear invested in their “independence” and are readily willing to entertain arguments that differ from CMS’ interpretation of Medicare coverage. This is not to guarantee that any specific ALJ might not be more inclined to toe the line drawn by CMS, or that CMS may not try to crack down even further on ALJ independence, but the anecdotal evidence currently available is encouraging for providers.

In addition, OMHA’s issuance of its Case Processing Manual (available at https://www.hhs.gov/about/agencies/omha/ the-appeals-process/case-processing-manual/index.html)

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has not had much effect. The intent in releasing the manual was to streamline the process used by the ALJs. It was hoped that standardized processing procedures would save time and effort on the part of OMHA, and also allow appellants to have a better idea of what to expect during each appeal, regardless of the assigned ALJ. This has proven to be fruitless thus far, at least from the IRF provider perspective.

Each ALJ appears to be continuing to run each hearing (and prehearing procedures) according to his or her own preferences, and appellants continue to be caught off guard by the differences in operations from one ALJ to the next. It is possible that some of the streamlined procedures are improving OMHA’s performance at the appeal intake and case file management level— all of which happens out of public view—but it is hard to determine how much such improvements are likely to impact the overall backlog of appeals.

Finally, the ALJ level of appeal continues to be the most provider-friendly forum. While the new ALJs certainly issue their fair share of negative decisions, evidence suggests that the ALJs continue to offer full and fair hearings to IRH/U providers. This is especially true for IRH/Us that may use a disproportionate amount of time during each hearing due to the complex and extensive coverage criteria applicable to inpatient hospital rehabilitation services under the Medicare program. Given the extent of the backlog, it could be expected that the ALJs, especially the new ones, may be very impatient with IRH/Us as appellants due to the length of time it takes to provide adequate testimony. The new ALJs, however, seem to be just as willing to listen to appellant presentations as the existing ALJs, though there may be exceptions.

There are pros and cons to these observations. It is certainly advantageous to IRH/Us for the new ALJs to maintain their independence and discretion. However, the failure of the new ALJs to adopt new procedures for streamlining the appeals process continues to leave appellants in the dark about what to expect from hearing to hearing and perhaps continues to feed the appeal backlog (though there is some question whether simple case processing steps can meaningfully impact the delay anyway). Nonetheless, additional capacity in the form of more ALJ teams is a welcome development in terms of chipping away at the ALJ backlog.

Selecting the Etiologic Diagnosis

Lisa Werner, MBA, MS, CCC-SLP

As we discussed last month, the responsibility for selecting impairment group codes (IGC) and etiologic diagnoses falls on the shoulders of both prospective payment system (PPS) and hospital coders. The purpose of IGCs is to indicate reasons for admission within a system of classification. However, these codes won’t always be exact due to the nature of the system, which offers only 21 choices for admission reasons. Etiologic diagnosis codes are ICD-10 codes meant to reflect the primary condition that resulted in an inpatient rehabilitation hospital stay.

Given the level of detail, these codes provide more specific descriptions as to why a patient required rehabilitation services. While selecting etiological diagnosis codes may seem simple enough, patients often present with complicated conditions that are difficult for physicians to clearly document, making final coding decisions far more challenging. This leaves PPS coordinators and coders in the difficult position of having to deconstruct each case, digest a myriad of factors indicated in each physician’s documentation, and make subjective decisions about which ICD-10 codes best support each case. This article will cover some of the most common code selection errors I see during audits.

First, hospital coder roles vary widely among providers. However, they typically review patient records around day 4 of each patient’s stay in search of the conditions that required inpatient rehabilitation. Then, they produce initial coding summaries that provide PPS coordinators with the necessary information to either enter codes onto the IRF-PAI or validate the codes already entered by the coder. Typical industry practice is for coders to identify both etiological diagnoses and comorbidities during initial chart reviews and finalize the codes during discharge reviews.

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Coders also assign codes for both the inpatient rehabilitation facility–patient assessment instrument (IRF-PAI) and the UB-04, which are not always the same. Coding records for rehabilitation stays is a different process than coding for acute care stays. Etiologic diagnoses recorded on the IRF-PAI will all be active conditions, and they may remain consistent with the reasons patients were initially admitted to acute care (as is the case for stroke patients). However, because the hospital will have already reported the diagnosis on the acute care UB-04, the rehabilitation stay UB-04 should reflect either a late effect code, a symptom code or an after-care code.

or unit due to a stroke are most commonly seen after newly diagnosed cerebral vascular accidents. In these cases, the etiological diagnoses would be acute strokes coded to the specificity of the physicians' documentation.

In an ideal case, the documentation should indicate the location of the condition within the brain, the laterality and the root cause. However, the principle UB-04 diagnosis will be different, with the acute care documentation reflecting the deficits with which each patient presents. An example would be hemiparesis following a cerebral infarction affecting right dominant side.

Another difference between these two processes is how conditions with no definitive diagnosis are handled. In acute care, conditions documented as “suspected,” “possible,” “probable” or “rule out” can be included on the bill. In a rehabilitation setting, this is not the case; unless the condition is definitively diagnosed, it cannot be included on the IRF-PAI. Because of this, PPS coordinators should work with coders to verify that only conditions with definitive diagnoses are entered into the IRF-PAI coding summary.

In some circumstances, patients are sent to an IRH/U following a hospitalization for separate conditions that have exacerbated the symptoms of a prior stroke. The etiological diagnosis for this condition should be coded as “late effects of a stroke.” This is to highlight that the patient has received rehabilitation for the same condition in the past and is returning for further treatment.

IRF-PAI codes may also include active symptoms that help explain the deficits that necessitate rehabilitation stays. However, some symptoms are considered inherent to each condition and should not be listed separately.

The IRF-PAI Training Manual also warns against including codes for conditions diagnosed on either the day of discharge or the day before discharge. Since this is not the case for the UB-04, PPS coordinators should work with coders to verify proper code capture on the IRF-PAI. In addition to all this, the IRF-PAI also contains three fields for etiological diagnoses, further complicating matters for coders.

As previously stated, etiological diagnoses are meant to describe the primary reasons for which patients are admitted to rehabilitation. In the vast majority of cases, this will be a single ICD-10 code. Three fields are included for etiological diagnoses because of the combination codes included with the implementation of the ICD-10 coding paradigm.

These combination codes were created to help describe the specifics of each patient’s condition. In some cases it will take all three fields to accurately describe a single condition.

Other ailments, such as polytrauma, often require two or three fields to accurately describe the conditions that led to an inpatient rehabilitation admission. These include the following conditions: multiple fractures, major multiple trauma, brain injury with a skull fracture, spinal cord injury with a spinal fracture, brain injury with two fractures or an amputation, or spinal cord injury with two fractures or an amputation.

Next, let’s take a look at specific impairments and discuss the nuances of producing an etiological diagnosis for each.

Stroke Patients admitted to an inpatient rehabilitation hospital

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Traumatic Brain and Spinal Cord Injuries Patients admitted to IRH/Us often come directly from an acute care setting. However, in some cases, patients may experience complications that result in readmissions. This produces situations where the etiological diagnosis recorded upon admission to an IRH/U may not reflect the conditions seen in acute care. Fortunately, the ICD-10 paradigm has baked-in flexibility, giving coders access to coding conditions by offering a seventh character option. In order to thoroughly describe trauma codes, coders need to know three important variables: is the condition being actively treated (code A), will it be treated in subsequent encounters (code D), and is treatment due to sequela from the original condition (code S)?

Initial rehabilitation encounters are coded with codes ending in “A.” When active treatment for the condition has ended and a patient is receiving only routine care, the codes end in “D.” If a patient is being treated for complications that arise as a direct result of the condition, the code will end in “S.” To help accurately code trauma, physician documentation should include the following elements: when the trauma occurred, how it happened, its location within the brain or spinal column, the impairments or deficits it caused, the dominate side of the body, and any details related to loss of consciousness.

Quadriplegia and Paraplegia When using IGCs 04.110-04.1222 and 04.210-04.2222, diagnosis codes should reflect the injury that caused the initial paraplegia/quadriplegia. Quadriplegia and paraplegia ICD-10 diagnosis codes are often paired with equivalent impairment groups, but I recommend against coding these conditions with redundant information.

When using IGCs that indicate either complete or incomplete quadriplegia/paraplegia, make sure that the etiological diagnoses indicate complete or incomplete spinal cord

injuries as well. If there is insufficient information to determine whether the injuries are complete or not, use the IGC for unspecified quadriplegia/paraplegia. Using unspecified codes is not recommended, but they are necessary in isolated cases.

Fractures Using seventh character flexibility is also relevant when coding fractures. To accurately describe fractures, the coder needs to know the same variables stated previously: is the condition being actively treated (code A), will it be treated in subsequent encounters (code D), or is treatment due to sequela from the original condition (code S)?

Physician documentation should indicate the laterality of fractures, whether or not they were displaced, and fracture types. This information helps make sure that coders are able to assign correct ICD-10 codes.

Using IGC 08.4, “Status Post Major Multiple Fractures” indicates that the patient suffers from two or more fractures in weight-bearing bones. One of these fractures must be located in the lower extremities, and, if the primary fracture is used as the etiological diagnosis, make sure to include at least one other weight-bearing bone fracture as a comorbidity. In these cases, it is acceptable to use more than one ICD-10 code for the etiological diagnosis.

Major Multiple Trauma IGC 14.9, “Other Multiple Trauma” should be used when patients present with two or more injuries to systems/sites other than the brain or the spine (for example, a traumatic fracture falls under this IGC). If brain injuries or spinal cord injuries are also present, the impairment group changes to either 14.2 or 14.3, respectively. If both a brain injury and a spinal cord injury are present, the impairment group changes to 14.1. In any of these cases, there are justifiable reasons to use more than one etiologic diagnosis code on the IRF-PAI. When coding major multiple trauma with brain and/or spinal cord injury, it is best to code the specific condition.

When using 14.2, always code etiological diagnoses with the cause of the brain injury. When using 14.3, always code the cause of the spinal cord injury.

In order to facilitate selection of the most accurate codes, physician documentation should indicate the date of the accident, the type of injury, the location of the injury, and any impairments it caused.

// PPS coordinators shoulder a substantial responsibility in selecting correct IGCs. And, while PPS coordinators having strong working relationships with the hospital coders is essential to this process, PPS coordinators, coders, and physicians must all work together to make sure that coding is as precise as it can possibly be. hospital coders is essential to this process, PPS coordinators, coders, and physicians must all work together to make sure that coding is as precise as it can possibly be. Coders will need to query physicians about incomplete or imprecise documentation. PPS coordinators will need to have discussions with physicians in order to determine their primary concerns for each patient. All situations where the correct codes are not readily apparent will need to be clarified, and this can only be done through a collaborative approach involving all three of the aforementioned positions. Remember, coders cannot query in a manner perceived as leading, and, as a result, cannot engage in leading discussions with physicians. For this reason, it is imperative that PPS coordinators are involved in coding for IRF-PAI completion to make sure that all questions, regardless of who asks them, are answered in a timely manner conducive of the most accurate coding decisions.

As I said last month (and probably will again next month when discussing comorbidities), to make sure coding is thoroughly accurate, it really does “take a village.”

In conclusion, PPS coordinators shoulder a substantial responsibility in selecting correct IGCs. And, while PPS coordinators having strong working relationships with the

AMRPA Magazine / May 2018 13

MedPAC’s Annual March Report to Congress Includes FY 2019 Payment Recommendation for Inpatient Rehabilitation Hospitals/Units and Other Updates

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

Highlights:

Right on the Ides of March, at the start of some eager spring flowers and hopefully the last whisper of snow in the forecast, the Medicare Payment Advisory Commission (MedPAC) published its annual March Report to Congress, Report to Congress: Medicare Payment Policy. The primary focus of the report is the analysis of payment adequacy for each type of Medicare provider and recommendations for fiscal year (FY) 2019 updates. Specific to inpatient rehabilitation hospitals and units (IRH/Us), MedPAC concluded that aggregate Medicare margins remained high and estimated the margin for 2018 will be 11.9 percent. However, this year in addition to the standard analyses, MedPAC continued its focus on post-acute care (PAC) providers, a unified PAC payment system, and included a recommendation based on the postacute care prospective payment system (PAC PPS) it developed, and that was included in the commission’s June 2016 Report to Congress: Medicare and the Health Care Delivery System. However, unlike previous years, MedPAC did not reflect on managed care and its impact on the inpatient rehabilitation field.

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Medicare margins remain high.

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MedPAC recommends 5 percent decrease.

I. Payment Adequacy In assessing payment adequacy, MedPAC looks at various indicators, which for IRH/Us it found to generally be positive. These indicators are:

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Blended payments proposed.

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Beneficiaries’ Access to Care ––

Capacity and Supply of Providers

––

Volume of Services

Quality of Care

Providers’ Access to Capital

Medicare Payments and Providers’ Costs

After making this analysis the commission recommended the following: “The Congress should reduce the fiscal year 2019 Medicare payment rate for inpatient rehabilitation facilities by 5 percent. (Additionally, the Commission reiterates its March 2016 recommendations on the inpatient rehabilitation facility prospective payment system. See text box, p. 276).�

The referenced recommendations state: Recommendation 9-2: The Secretary should conduct focused medical record review of inpatient rehabilitation facilities that have unusual patterns of case mix and coding.

Recommendation 9-3: The Secretary should expand the inpatient rehabilitation facility outlier pool to redistribute payments more equitably across cases and providers.

A. Beneficiaries’ Access to Care 1. Capacity and Supply of Providers As for the number of IRH/Us, after decreasing in prior years, the total number of providers increased between 2013 and 2014 and continued to grow in 2016, reaching 1,888 providers. See Table 10-4 below. Rehabilitation units constituted about 77 percent of providers in 2016 with the remaining 23 percent being freestanding hospitals. Yet, units only accounted for 50 percent of discharges in that they tend to be smaller than the rehabilitation hospitals.

Over time, the number of rehabilitation units has declined as well. For-profit providers constituted 31 percent of the field. However, freestanding hospitals were more likely to be for-profit than units (73 percent vs. 19 percent, respectively).

About 52 percent of discharges were from for-profit facilities. As noted last year, the number of hospital beds and nonprofit freestanding hospitals has declined and their for-profit counterparts have increased.

A summary of the payment adequacy criteria findings follow:

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Between 2004 and 2016, the total number of IRH/Us fell by 9 percent and the number of non-profit IRH/Us fell by 12 percent, while the number of freestanding and for-profit providers rose by 26 percent and 27 percent, respectively. In 2016, 31 providers closed; most were hospital-based units. Meanwhile, 37 new freestanding hospitals opened. Slightly more than half of the new entities were hospital-based units. Of the hospital-based units, about a third were for-profit. All but one of the new freestanding hospitals were for-profit. Acute care hospitals may find that units help reduce inpatient lengths of stay.

Previous commission analyses found that hospitals with rehabilitation units have higher inpatient margins than hospitals without such units (Medicare Payment Advisory Commission 2015). In 2016, the average IRH/U occupancy rate remained at 65 percent. Occupancy rates were higher in freestanding rehabilitation hospitals (68 percent) than in hospital-based rehabilitation units (62 percent).

These rates suggest that capacity is more than adequate to meet demand for services, according to MedPAC. 2. Volume of Services Inpatient hospital cases grew in 2016 to 102 cases per 10,000 fee-for-service beneficiaries, which is up 1.4 percent from 2015. MedPAC states that “compared with all Medicare beneficiaries, those admitted to IRFs in 2015 were disproportionately over age 85.” The percent of Medicare discharges remained at 60 percent of total discharges. Between 2015 and 2016 the number of cases grew 2.4 percent to approximately 391,000 patients.

3. Quality of Care The commission examines three quality indicators: risk adjusted change in functional and cognitive status during the IRH/U stay, rates of discharge to the community and to skilled nursing facilities (SNFs), and rates of readmission to acute care hospitals. Most measures were steady or

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improved from 2011 to 2016. However, both readmission measures increased slightly from 2015 to 2016.

The rate of avoidable readmissions during a rehabilitation stay rose from 2.4 percent in 2015 to 2.5 percent in 2016.

The rate of discharge to a SNF dropped from 6.8 percent in 2015 to 6.7 percent in 2016. The rate of readmissions during the 30 days after discharge increased from 4.1 percent in 2015 to 4.4 percent in 2016. Discharge to the community rose from 76 percent in 2015 to 76.9 percent in 2016. With respect to functional outcomes, the mean motor functional independence measure gain increased from 23.6 in 2015 to 24.4 in 2016, and the mean cognitive functional independence measure score increased from 3.9 in 2015 to 4.0 in 2016.

MedPAC did note, as it has in prior years, that since payment is based in part on functional and cognitive change, providers may have incentives to “minimize their assessments of patients’ levels of function at admission. If IRFs minimize patients’ functional status at admission, gains in function during the patients’ stays will be overstated.” MedPAC also examined the variation in quality measures across quintiles.

These are summarized in Table 10-8 on page 19.

B. Providers’ Access to Capital As in past years, MedPAC concluded that most rehabilitation units had adequate access to capital through their acute care hospitals. Overall, access to capital remained strong in 2016 and 2017 because of low interest rates. Yet “the three major bond-rating agencies (Fitch Ratings, Moody’s Investor Services and Standard & Poor’s Ratings Services) reported that nonprofit hospitals in 2016 experienced slowing of revenue growth from the previous year, rising expense growth, and slightly lower facility-wide operating profits (Fitch

Ratings 2017, Moody’s Investors Service 2017, Standard & Poor’s Ratings Services 2017). The three largest for-profit hospital systems reported a similar trend (Community Health Systems 2017, Morningstar Document Research 2017a, Morningstar Document Research 2017b).”

Expense growth picked up because of increases in the cost of nursing labor, information technology, and pharmaceutical and medical supplies— which affect IRH/Us and acute care hospitals. As for freestanding providers, MedPAC assumed there is adequate access and commented on HealthSouth’s good access to capital as reflected in its expansion to new hospitals and the purchase of a home health care chain in 2014.

C. Medicare Payment and Providers’ Costs: Margins Remained High MedPAC continued to scrutinize IRH/U margins. Overall, the average Medicare margin declined in 2016, after growing between 2009 and 2015, but remained high at 13.0 percent in 2016, according to MedPAC’s assessment of aggregate margins. Medicare margins in freestanding hospitals declined by 1.2 percentage points in 2016 but, at 25.5 percent, still remained “very high.” Hospitalbased unit margins were generally lower, but onequarter of units had Medicare margins greater than 11 percent, “indicating that many hospitals can manage their IRF units profitably.” Units’ lower margins were a function of higher unit costs as the result of several factors which MedPAC identified in past years as well.

First, units are smaller than freestanding hospitals and may achieve fewer economies of scale. Second, units appear “to be less stringent in their cost control, perhaps because

they are far less likely than freestanding IRFs to be forprofit and therefore less likely to be focused on controlling costs to maximize returns to investors.” Also, rehabilitation units may provide a different mix of services, “including more costly therapy modalities.” Third, there are notable differences in hospital-based and freestanding IRH/Us’ mix of cases, and “some case types may be less profitable, resulting in higher margins for facilities that admit smaller shares of these cases.” Finally, units may differ in their assessment and scoring of patients’ motor and cognitive function,“ which can result in payments that are not properly aligned with resource costs.” The commission found that both freestanding hospitals’ and units’ payments exceeded marginal costs substantially—19.3 percent for units and 40.9 percent for freestanding hospitals—“suggesting that IRFs with available beds have a strong incentive to admit Medicare patients.”

The commission also focused on the growth in cost in assessing overall margins. It found that from 2009 to 2015, cost growth slowed considerably; over that time, cumulative growth in cost per discharge was 8.5 percent.

Cost growth was slower for this period for all types of IRH/Us, but particularly for freestanding for-profit hospitals.

For the same period, the cumulative growth in cost per discharge for freestanding for-profits was 2.0 percent. The cumulative growth in payments per discharge grew more rapidly than costs, climbing 14.3 percent in the aggregate and 15.1 percent for freestanding for-profits. Aggregate margins climbed from 8.4 percent in 2009 to 13.8 percent in 2015. However, between 2015 and 2016, cost growth exceeded payment growth for the first time since 2009.

The aggregate cost per discharge increased 3.4 percent,

AMRPA Magazine / May 2018 17

while payments per discharge increased 3.2 percent.

As the result of its analyses, MedPAC concluded that margins among the different types of providers vary widely. In 2016 aggregate margins for rehabilitation units were 1.2 percent and for rehabilitation hospitals they were 25.5 percent. Hospitals and units with less than 25 beds tended to have negative margins. See Table 10-9 on page 19.

As it stated last year, MedPAC continues to believe that several factors may underlie the differences in margins between rehabilitation units and freestanding hospitals.

They include several noted above and reiterated here:

Units are less stringent in their cost control and had higher costs across all cost categories.

Units are likely to achieve fewer economies of scale than rehabilitation hospitals, possibly because they are smaller and have fewer cases.

Units have lower occupancy rates vs. freestanding hospitals (62 percent vs. 68 percent).

Units tend to admit more stroke cases than hospitals (23 percent vs. 17 percent).

Units are more likely to be non-profit and therefore less “focused on controlling costs to maximize returns to investors.”

Units’ occupancy rates are lower than freestanding rehabilitation hospitals (59 percent vs. 68 percent).

Units have a higher number of cases with extraordinarily

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high costs. In 2016, 13 percent of unit cases were outlier cases vs. 3 percent of freestanding IRFs.

Units have a different mix of cases, with their share of stroke patients at 24 percent vs. 17 percent for hospitals.

After its extensive analysis of margins, MedPAC recommended a 5 percent decrease in the FY 2019 update for IRH/Us and, as noted above, reiterated its recommendations from its 2016 report. It projects that the aggregate Medicare margin will be 11.9 percent for rehabilitation hospitals and units in 2018. Note however that MedPAC’s recommendations are just that, and Congress must act on them in order for them to take effect.

AMRPA Letter to MedPAC In January 2018, AMRPA sent a letter to MedPAC objecting to the then proposed payment reduction. It was published in the February AMRPA magazine and is accessible on the AMRPA website at amrpa.org.

II. Post-Acute Care: Increasing the Equity of Medicare’s Payments within Each Setting In this chapter, the commission continues to promote adoption—even partial adoption—of the PAC PPS it developed in 2016 in response to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act mandate.

Under the Act, the commission set forth the outline of a unified payment system to be used in the four PAC settings.

The commission found that a unified PAC PPS could use administrative Medicare data to estimate payment rates for

AMRPA Magazine / May 2018 19

a stay based on a patient’s characteristics, not the site of service or the amount of therapy furnished. The PAC PPS would address one of MedPAC’s key concerns: that the SNF and HHA PPSs encourages providers to furnish services “of questionable value and advantage providers that avoid medically complex patients.” In its June 2017 report, the commission recommended that the new payment system begin to be implemented in FY 2021. Note that MedPAC’s PAC PPS does not include any functional data, which the commission said could be addressed at a later date.

unified PAC PPS and setting-specific relative weights before the implementation of a PAC would give providers more time to adjust their practices and costs to the incentives of the new system, according to MedPAC. With closer alignment of payments and costs and the redistribution of payments across providers, policymakers then could consider establishing a level of payment that more accurately reflects the costs of care. When the PAC PPS is fully implemented, its relative weights would be used exclusively in establishing payments for providers in the four PAC settings.

However, before implementing a unified PAC PPS, and in order to have partial adoption of the new system MedPAC recommended, this chapter reviews MedPAC’s views of the problems with the current systems, its proposed PAC PPS, and then explores redistributing payments for different conditions. The commission recommends that Congress direct the secretary to begin blending the relative weights of the setting-specific payment systems and the unified PAC PPS in 2019 “because the resulting payments would be more closely aligned with the cost of care across all conditions, the equity of the program’s payments would increase.” Under this approach, each PAC setting’s total payments would be kept at the recommended level while payments would be redistributed within each setting based on a provider’s mix of patients, costs and therapy practices. Blending the

MedPAC also stated that the recommendation to blend the relative weights does not detract from the commission’s recommendations to revise the SNF and HHA payment systems. Because the PAC PPS is on a longer implementation timetable, Medicare must continue to improve its settingspecific payment systems in the interim. To address the level of payments in the PAC settings, the commission recommends lower payments for HHAs and IRH/Us and to provide no updates to the payments for SNFs and LTCHs.

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In this chapter, MedPAC recommended: The Congress should direct the Secretary to begin to base Medicare payments to post-acute care providers on a blend of the setting-specific relative weights and unified PAC prospective payment system relative weights in FY 2019.

FAIR FUND Fund for Access to Inpatient Rehabilitation

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LEARN MORE & JOIN TODAY www.thefairfund.org We are the Fund for Access to Inpatient Rehabilitation, a Common Legal Defense Fund Composed of America’s Top Inpatient Rehabilitation Hospitals and Units.

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For more information, or to speak with a FAIR Fund leader or staff member, contact Rebecca Schnorf at rschnorf@firminc.com or at (217) 321-2477.

Draft IMPACT Transfer of Health Information Measures Shift Focus to Medication Information

On March 20, the Centers for Medicare and Medicaid Services (CMS) released for public comment draft measure specifications for the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) Transfer of Health Information quality measures. Specifically, CMS sought stakeholder input on two measures that would collect data on the transfer of medication information at a patient’s post-acute care (PAC) discharge or transfer. The measures are:

Mimi Zhang, Senior Policy and Research Analyst, AMRPA

Highlights: »»

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CMS issues revised Transfer of Health Information quality measures, picking up from work it started in 2016. easures would address the M transfer of a “Medication Profile” at discharge/transfer.

1.

Medication Profile Transferred to Provider

2.

Medication Profile Transferred to Patient

CMS developed two measures because it believes there are distinct cohorts and recipients of the medication information: 1. the cohort of patients who are discharged/transferred to the care of a subsequent provider who is the recipient of the medication profile; and 2. the cohort of patients who are discharged to their home or other living arrangement and are the recipients of their medication profile. Both measures would be collected at the time of discharge/transfer.

The IMPACT Act requires CMS to develop measures reflective of transfer of health information and care preferences at transitions for PAC settings (inpatient rehabilitation hospitals and units [IRH/Us], skilled nursing facilities [SNFs], long-term care hospitals [LTCHs], and home health agencies [HHAs]). In the Act, this quality domain is addressed as: “(E) Accurately communicating the existence of and providing for the transfer of health information and care preferences of an individual to the individual, family caregiver of the individual, and providers of services furnishing items and services to the individual, when the individual transitions— (i) from a hospital or critical access hospital to another applicable setting, including a PAC provider or the home of the individual; or (ii) from a PAC provider to another applicable setting, including a

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different PAC provider, a hospital, a critical access hospital, or the home of the individual.”

The Act further mandates the development and use of standardized patient assessment data elements, which CMS refers to as SPADEs, across the four PAC settings. AMRPA submitted a comment letter with input from our Quality Committee.

Background and Prior Work The draft measures released in March are actually the second iteration of Transfer of Health Information measures. The first iteration, released by CMS in 2016, consisted of two measures: Transfer of Health Information at PAC Admission, and Transfer of Health Information at PAC Discharge. Those measures proposed collecting a far wider range of patient data elements beyond medication information, including but not limited to functional and cognitive status, medical conditions and comorbidities, and discharge instructions.

In addition, the Transfer of Health Information at PAC Admission measure asked PAC providers to indicate the types of patient information received by the PAC from the upstream care provider, which in most cases is the acute care hospital. In response to those measures, post-acute stakeholder groups including AMRPA commented to CMS that the nature and scope of the proposed information collection were overly burdensome, and duplicative of patient data already being collected elsewhere on PAC assessment forms. Furthermore, the Transfer of Patient Information at Admission measure carried the risk of holding PAC providers somehow accountable for the behavior of upstream referral sources over which PAC entities have limited influence.

In the summer of 2017, CMS conducted a pilot test of the Transfer of Health at PAC Admission and Discharge measures and in February published a report on pilot test finding. CMS also published a technical expert panel (TEP) report of PAC subject matter experts who were convened to review the test findings. Of note, CMS concludes in the latter report that “based on input from the TEP in August 2017…significant refinements have been made to the measure under development and implementation of the measures is delayed. The measure now being developed and refined will focus on the transfer of a medication profile at PAC discharge or transfer.” Both reports are available on the agency’s IMPACT Act Downloads webpage.

Route of Information Transfer CMS also seeks to better understand how PAC providers transfer patient information at discharge, and specifically the route or mode (e.g., electronic, verbal, paper-based) providers use to do so. The measure specification report references the 2014 American Hospital Association survey showing that 57 percent of acute care hospitals engage in electronic health information exchange (HIE) with PAC providers, and more than half of those exchanges are limited to only one-way information transfer (i.e., hospital can only transmit data to PAC or vice versa). CMS recognizes that PAC providers were not eligible to participate in Medicare’s

EHR “Meaningful Use” Incentive Programs. The agency cites literature finding that PAC providers lag behind acute care hospitals and physician offices in both EHR and HIE adoption, and experience other barriers to adoption.

As such, the draft measures propose to require providers to indicate on the Inpatient Rehabilitation Facility Patient Assessment Instrument (IIRF PAI) the route used to transmit medication information to either the next site of care or the patient/family/caregiver (see items Q1B and Q2B of the draft measure below). CMS says this information could potentially be collected as a SPADE and would be used for the public reporting of information on IRF Compare. However, it would not be used to calculate provider performance on the measure.

Considerations Under the current administration, CMS is ostensibly committed to reducing regulatory reporting burden and espouses “Patients Over Paperwork” as its guiding tenet. While the second iteration of the Transfer of Health Information measures do appear to be pared down from their original form, the devil is indeed in the details and especially so when it comes to operationalizing quality measures. For instance, will the Medication Profile data elements be classified as standardized patient assessment data information and thus be mandatory reporting on the IRF PAI? If so, would the IRF PAI need to include information on all of a patient’s medications?

CMS’ report fails to specify such granular implementation details associated with the collection of these clinical data.

Hence, the public comment window presented an opportunity for the provider community to discuss with the agency about measures issues that bear further consideration.

The balance of this article summarizes the draft specifications for the Transfer of Health Information: Medication Profile quality measures. CMS’ specification report, Draft Specifications for the Medication Profile Transferred Measures for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-term Care Hospitals, and Home Health Agencies, is available for download on its quality measures public comment webpage. With the public comment opportunity, the agency also released a series of questions to which it seeks stakeholder feedback.

Those questions are included at the end of this article.

Both measures would be calculated in the same way: 1. Calculate the denominator count: The total number of stays ending in discharge/transfer to either the next care setting or to home.

2. Calculate the numerator count: The total number of stays where the current medication profile was provided to the next care setting or to the patient/ family/caregiver at time of discharge or transition.

3. Calculate the provider’s observed score: Divide the numerator by the denominator.

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Draft Measure Q1: Medication Profile Transferred to Provider at Discharge/Transfer

Measure Q1 Summary Description: This process-based measure calculates the proportion of patient/resident stays with a discharge or transfer assessment indicating that a current medication profile was provided to another provider at the time that the patient/ resident was discharged or transferred to a short-term general hospital, SNF, intermediate care, home under care of an organized home health service organization or hospice, hospice in an institutional facility, swing bed, IRH/U, LTCH, Medicaid nursing facility, inpatient psychiatric facility or critical access hospital.

The measures would be nearly identical across PAC settings. However, as noted above, the patient inclusion criteria are not aligned and vary by payer, so the underlying patient populations are not identical. CMS has previously said this lack of harmonization is because PAC settings have do not have standardized requirements for completing patient assessments by payer.

Definitions I. Medication Profile CMS sees the Medication Profile as a comprehensive summary of information for the current prescribed and over the counter (OTC) medications, nutritional supplements, vitamins, and homeopathic and herbal products administered by any route to the patient/ resident. Medications also include total parenteral nutrition (TPN) and oxygen. A medication profile also includes information about the patient/resident that is relevant to the medications. Documentation sources for medication profile information include electronic and/or paper records, including discharge summary records, a Medication Administration Record (MAR), Intravenous Medication Record (IVAR), home medication list and physician orders.

CMS states that the medication profile should include at least all of the following data elements.

Some are required only when applicable to the patient or medication, and are indicated as such.

A. Patient Information on the Medication Profile 1. Patient name 2. Patient date of birth 3. Primary physician name and contact information 4. Height and date taken, if applicable

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Draft Measure Q2: Medication Profile Transferred to Patient at PAC Discharge/Transfer

Measure Q2 Summary Description: This process-based measure calculates the proportion of patient/resident stays with a discharge/transfer assessment indicating that a current medication profile was provided to the patient/family/ caregiver at the time that the patient/resident was discharged/ transferred to a private home/ apartment, board/care, assisted living, group home, transitional living or home under care of organized home health service organization or hospice.

5. Weight and date taken, if applicable 6. Patient active diagnoses and any other diagnoses that have medication implications 7. Known medication and other allergies 8. Known drug sensitivities and reactions 9. Patient preferences (e.g., preferred packaging such as no childproof lids, form of medication such as time-released medication, how medication information provided to patient), if applicable 10. Patient adherence strategies (e.g., alarms, drug diaries), if applicable 11. Patient ability to understand/accept condition(s) and importance of taking medications as prescribed B. Medication Information – Complete for each medication 12. Name (generic and proprietary names, if applicable) and strength 13. Dose 14. Route of medication administration 15. Frequency 16. Directions 17. Special instruction (e.g., crush medications), if applicable 18. (For held medications) Reason for holding medication and when medication should resume 19. Purpose/indications/contraindications 20. Prescriber (for prescribed medications only) 21. When the last dose of the medication was administered by discharging/ transferring provider, if applicable 22. When the final dose of the medication should be given, if applicable 23. Patient education provided about potential risks/ side effects/contradictions and when to notify

prescriber (for profile provided to patient/family/caregiver) 24. Patient adherence with the medication therapy 25. Relevant lab test results to guide medication management (e.g., serum creatinine), if applicable

Measure specification information applicable to both measures Measure Type: Process Data Sources: These measures are calculated from data on the PAC assessment forms (IRF-PAI, MDS, OASIS, LCDS) Data Collection Time Point: Patient Discharge/Transfer Measure Denominator Inclusion Criteria: • For IRH/Us, the denominator is the total number of Medicare Part A and Medicare Advantage (Part C) patient stays ending in discharge/transfer • LTCH: Total number of LTCH patient stays, regardless of payer, ending in a discharge/transfer to another setting • SNF: Total number of SNF Medicare Part A covered resident stays ending in a discharge/transfer to another setting • HHA: denominator for this measure is the number of Medicare Part A and Medicare Advantage (Part C) and Medicaid home health quality episodes ending in a discharge/transfer to another setting Risk adjustment: This measure will not be risk adjusted.

Measure Score: Percentage, where a higher indicates a better performance.

Measure specification information applicable to Measure Q1: Medication Profile Transferred to Provider at Discharge/Transfer Target Population: Qualifying patients/residents discharged or transferred to another provider from LTCH, SNF, IRH/U, or HHA Measure numerator: Number of patient/resident stays/episodes with a discharge/transfer assessment indicating a current medication profile was provided to the subsequent provider at the time of discharge/transfer.

Measure Denominator: Total number of stays/episodes ending in the discharge/transfer to a: • Short-term general hospital/STACH • IRH/U • LTCH • SNF • Swing bed • Medicaid nursing facility • Intermediate care • Home under care of an organized home health service organization or hospice • Hospice in an institutional facility • Inpatient psychiatric facility • Critical access hospital Measure specification information applicable to Measure Q2: Medication Profile Transferred to Patient at PAC Discharge/Transfer Target Population: Qualifying patients/residents discharged or transferred from LTCH, SNF, IRH/U, or HHA settings to a private home/apartment (apt.), board/care, assisted living, group home, transitional living, or home under care of organized home health service organization or hospice.

Measure Numerator: Number of patient/resident stays/episodes with a discharge/transfer assessment indicating a current medication profile was provided to the patient, family and/or caregiver at the time of discharge/ transfer.

Measure Denominator (same for all PAC settings): Total number of stays/ episodes ending in the discharge/transfer to a: • Private home/apartment • Board/care • Assisted living • Group home • Transitional living • Home care under care of organized home health service or hospice

II. Route of Information Transmission CMS proposes the following four routes/ modes of information transfer: 1. Electronic health record (EHR). In addition to direct EHR transfer, CMS provided the following illustrative examples that would also be considered EHR transfer: • Providing patients with remote access to view their medication profile through the PAC provider’s EHR portal (website).

• Electronically transmitting the medication profile data from the PAC provider’s EHR to a patient’s personal health record or a health application.

• Providing the receiving provider or care team member access to the PAC provider’s EHR through a portal (website) or other means, such as remote or onsite access.

2. Health Information Organization (HIO). Illustrative examples include: • Exchanging the medication profile between a PAC provider and the receiving hospital through a state HIO. • A PAC provider exchanges medication information through a HIO that provides a web interface so that a receiving provider and the patient can view and query the information.

• A PAC provider’s EHR vendor participates with other EHR vendors in a health information exchange network that allows the PAC provider to transfer medication profile information with providers participating in that network in order to coordinate care.

• Sending medication profile information via secure email messaging (e.g., direct secure messaging) to the patient or receiving provider.

3. Verbal transmission. Illustrative examples include: • Receiving provider participates in discharge rounds at the discharging PAC facility.

• Telephone conversation with physician or nurse at receiving facility/agency to relay medication information at PAC provider discharge.

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• Reviewing the patient’s medication profile reviewed with them at discharge.

4. Paper-based transmission. Examples include: • PAC provider sending the subsequent provider a paper copy of a transfer form that includes the medication profile, and the form is sent with the ambulance or medical transportation company.

• PAC provider sends a fax of the discharge summary, which includes the medication profile, to the patient’s next healthcare provider.

CMS Questions for Stakeholder Feedback in the Public Comment Opportunity Measure Titles

Whether the measure titles clearly capture the measure concept across the PAC settings

Any other suggestions for the measure titles

Measure and Specifications

Potential impact and any unintended consequences of the measures (either positive or negative)

Potential measure exclusions

Potential benefits, if any, to aligning PAC discharge destinations/locations/status/ disposition across PAC assessment instruments

Medication Profile

The definition of a medication profile

The types of medications to be included in the medication profile

Differences, if any, in what information should be included in a medication profile provided to a healthcare provider as compared to a medication profile provided to the patient/family/caregiver

Whether discontinued medications should be included in the medication profile. If included, provide suggestions of parameters for inclusion in the medication profile (e.g., medications that were initiated and discontinued during the PAC stay, or medications discontinued within the past week, etc.)

Whether it is feasible and important for the patient’s primary physician contact information to be included on the medication profile

Whether it is feasible and important to include an assessment of a patient’s ability to understand/ accept his or her condition and the importance of taking medications as prescribed

Whether it is feasible and important for the prescriber of each medication to be identified in the medication profile

For transfers from HHA to a subsequent provider, are there any issues with adding the response option of “NA – The agency was not made aware of this transfer timely”? Are there specific instances when this response option should be considered an allowable response?

Are there specific instances when this response option should not be considered an allowable response?

Route of Transmission of the Medication Profile

Whether consumers will find value in knowing the routes by which the information profile was transmitted (e.g., verbal communication).

Whether the medication profile description captures the most important sources of medication profile information

Whether the route of transmission information would inform consumer choice of providers/facilities.

The feasibility of collecting the medication profile data elements

Data elements to include in a medication profile.

(Please provide rationale for any new data elements not included in the draft definition.)

Although not required for this measure, if PAC providers would be able to transfer the medication profile electronically through their EHRs/EMRs.

Sufficiency of existing health IT standards to support interoperable exchange of the medications and data elements proposed in the draft medication profile.

Which data elements in the medication profile should be designated “if applicable."

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HHS OIG Finds High Rate of Claims Errors in Review of Medicare Outpatient Therapy Services

The Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) recently released a report detailing its findings of a review of Medicare Outpatient Therapy Services. The review examined physical therapy claims from July 1 through December 31, 2013. Threehundred randomly selected paid claims were examined as part of this probe, which were limited to only those claims submitted with place of service (POS) code 11, signifying the services were delivered in an office setting.

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

Highlights: »»

OIG found 61 percent of claims found be improperly paid with Medical necessity, coding and documentation errors to blame, says OIG.

»»

CMS disagreed with OIG Contractor’s Interpretation of Policy.

The OIG contracted an independent medical review contractor to review the claims. The contractor found that 185 of the 300 (61 percent) claims reviewed were deemed to be improper payments. Of the 185 claims determined to be an improper payment, 91 were found to lack medical necessity (30 percent of claims sampled), 145 were determined to be coded incorrectly (48 percent of claims sampled) and 112 had insufficient documentation (37 percent of claims sampled).

Medical Necessity In the report, the OIG provided a further breakdown of the 91 cases found to be lacking medical necessity by the medical review contractor (see Figure 1). The contractor found that 89 of the 91 cases were not reasonable because the amount, frequency and duration of the physical therapy services were not consistent with standards of practice. For 30 of the 91 claims, the medical review contractor stated it did not find any evidence in the medical records demonstrating that the services provided would have been effective. In the case of 28 of the 91 claims, the contractor stated the medical record failed to substantiate that skilled intervention by a physical therapist was necessary because the beneficiary was performing redundant and repetitive exercises that could have been performed as part of a home exercise program. Finally, for 26 of

AMRPA Magazine / May 2018 27

Figure 1: Types of Medical Necessity Errors

Figure 3: Types of Documentation Errors

the 91 claims, the contractor found a review of the medical record indicated that there was no expectation of significant improvement from a rehabilitative treatment program.

Medicare Coding As previously mentioned, of the 300 claims reviewed, the contractor found 145 had coding errors. Of those 145, 86 were found to be coded incorrectly because the timed units coded did not match time in the treatment notes. In addition, the OIG noted 78 of the 145 had missing required G-code modifiers for functional reporting, and 59 of the claims had incorrect codes billed for the service provided. See Figure 2.

Figure 2: Types of Coding Errors

Documentation Requirements The report also provided a further breakdown of the 112 claims found to be lacking proper documentation (see Figure 3). Of the 112, the medical review contractor determined 80 had a deficiency in the required plan of care in the medical record, such as containing vague goals, lacking a proper signature, or not listing the duration and frequency of the therapies. The contractor also found 74 of the claims had treatment note deficiencies in the documentation, such as not containing total treatment minutes for timed codes.

Finally, the OIG also noted that nine of the claims had recertification deficiencies because the record did not have a statement justifying the need for additional therapy after the initial therapy phase under the original plan of care.

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CMS Response In response to the draft report, CMS disagreed with some of the interpretations made by OIG’s independent medical review contractor of Medicare coverage guidelines pertaining to outpatient therapy services. One area in particular where CMS disagreed was with the interpretation pertaining to the requirement that there be an expectation of significant improvement. CMS stated this was contrary to its coverage policies and to the policy effected as a result of the court approved settlement in Jimmo V. Sebelius, which clarified that for care that is reasonable and necessary to prevent or slow further deterioration of function, coverage cannot be denied based on the absence of potential for improvement or restoration.

CMS said that in response to the report it would do its own review of the claims reviewed by the OIG contractor. Based on that review, CMS said it will determine whether it will pursue overpayments for these claims. In its final report, the OIG responded that it continued to disagree there was a misinterpretation of policy, emphasizing it only applied an improvement standard for those claims for beneficiaries who were on a rehabilitative therapy program and not to those on a maintenance therapy program. Further, the OIG emphasized each denied claim was reviewed by two reviewers, including a certified coder and a physician who is board certified in physical medicine and rehabilitation.

The full report, Many Medicare Claims for Outpatient Physical Therapy Services Did Not Comply with Medicare Requirements, is available on the OIG website.

AMRPA Holds Successful 2018 Spring Conference and Congressional Fly-In The American Medical Rehabilitation Providers Association (AMRPA) held three educational and networking events in Washington, DC, March 11-13, 2018, for its membership, including a Medical Directors Symposium, Rehabilitation Administrators’ Workshop, and the Leadership Forum and Congressional Fly-In. These events are a unique opportunity for AMRPA members to hear directly from policymakers in Congress, the Centers for Medicare and Medicaid Services (CMS), the Department of Veterans Affairs (VA), the Office of Management and Budget (OMB), the Medicare Payment Advisory Commission (MedPAC), and other agencies about key issues affecting inpatient rehabilitation hospitals and units (IRH/Us) and outpatient therapy providers. Additionally, the Congressional Fly-In connects attendees with their elected representatives through Capitol Hill meetings so medical rehabilitation providers can discuss the impact that federal policies have on the patients they serve.

AMRPA Members Converge on Washington, DC to Advocate on Behalf of the Field with Members of Congress

Leadership Forum and Congressional Fly-In: Advocating for the Field and AMRPA’s Policy Priorities The purpose of the Leadership Forum is to allow AMRPA members to hear directly from those who are making the policies that affect their daily and future operations, identify the challenges facing the field, and give them the opportunity to speak to their Congressional offices about these issues. AMRPA provides information on the policy issues affecting inpatient rehabilitation hospitals and units, such as denials by Medicare Advantage plans and the 60 Percent Rule, in addition to providing advocacy training to empower our members to advocate on their own behalf with their elected officials.

Many medical directors and administrators remained for the annual Leadership Forum and Congressional Fly-In and were joined by their colleagues who serve

AMRPA Magazine / May 2018 29

as the chief executive, chief financial, and chief operating officers of inpatient rehabilitation hospitals and units.

that would benefit from paperwork or burden reduction. CMS is seeking to be innovative with respect to these issues. It is seeking to make various websites more user friendly as well.

This year the meeting participants heard directly from:

James Mathews, PhD, Executive Director, Medicare Payment Advisory Commission (MedPAC);

David J. Shulkin, MD, Secretary, Department of Veterans Affairs;

Carla DiBlasio, Health Counsel, House Committee on Ways and Means;

Joe Grogan, Associate Director for Health Program at the Office of Management and Budget, Executive Office of the President;

Julie Nolan, Deputy Chief of Staff and Legislative Director for Rep. Patrick Meehan (R-PA), Member of House Ways and Means Committee;

Veronica Duron, Legislative Assistant, Office of Senate Minority Leader Senator Charles Schumer (D-NY);

Chrissy Fowler, Director, Payment Accuracy and Reporting Group, CMS;

Latesha Walker for Melanie CombsDyer, Provider Compliance Group, Office of Financial Management, CMS;

Susanne Seagrave, PhD, Deputy Director, Division of Institutional Post-Acute Care, Chronic Care Policy Group, CMS;

Tara McMullen, PhD, Senior Analyst and Government Task Lead, Division of Chronic Post-Acute Care, CMS;

Christine Grose, MS, RN, Nurse Consultant, Division of Chronic and Post-Acute Care, CMS;

Charles Padgett, RN, Nurse Consultant, Division of Chronic and Post-Acute Care, CMS;

Richard Kathrins, PhD, CEO, Bacharach Institute for Rehabilitation, and Chair, AMRPA Board of Directors on the state of the field;

Sam Fleming, Director, eRehabData®;

Martha Kendrick, JD, Washington Counsel to AMRPA, Akin Gump;

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

Susanne Seagrave, PhD Susanne Seagrave, PhD, noted that her office’s focus was on developing the inpatient rehabilitation hospital units’ payment policies for CMS, while other offices interpret them.

She then turned to CMS’ Patients Over Paperwork initiative.

The guiding principle for the initiative is an opportunity for CMS to reach out to stakeholders and invite comments on innovations, changes in regulations, and reducing burden.

Seagrave asked providers to give CMS feedback on any area

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Seagrave then spoke about the recent CMS documents that have been issued including a MLN Matters article titled,Inpatient Rehabilitation Facility (IRF) Medical Review Changes, MN Matters Number SE 17036, and Change Request 10482, (Transmittal 771) effective March 23, 2018 re: Clarifications of Instructions Regarding the Intensive Level of Rehabilitation Therapy Services Requirements.

She stated that they are a reiteration of existing policy wherein the standard for the delivery of therapy is that the preponderance of therapy is individual therapy. Group and concurrent therapy can be provided on a limited basis.

She noted that the MLN was issued by CMS’ Center for Program Integrity. Furthermore, that office issued a technical direction letter to Medicare contractors regarding what is supposed to be in the policy that is referenced in the MLN.

She then turned to the FY 2018 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) final rule and noted that CMS did acknowledge the burden of collecting the large amount of standardized patient assessment data in the proposed rule, and that those items were therefore withdrawn in the final rule. She said they are carefully considering all the ideas they received under the rule’s request for information, including those for the 60 Percent Rule. She again invited the audience to send any additional comments. She also noted that data on therapy modes and minutes has now been collected since October 1, 2015, and that CMS is looking at what has been received and what care is provided. She also mentioned the Tier Comorbidities project. A year ago CMS solicited comments on whether the comorbidities should be updated and if so, how. She asked the audience to let her know if this was still an area of interest.

Seagrave then discussed two other areas of interest to inpatient rehabilitation providers. The first was technical denials. She noted that clinicians should document in detail the frequency, duration, and intensity of therapy, discharge destination, and if possible documentation should start before admission or as early in the case as possible. Again, she asked for examples of detailed documentation requirements providers believe are unfair, excessive, duplicative, and not contributing to the quality of care. The second area was the development of the post-acute care prospective payment system (PAC PPS). She mentioned that CMS is reviewing MedPAC’s report on a PAC PPS and is considering its recommendations, but that no other action has occurred. Pursuant to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, CMS and the Secretary of the Department of Health and Human Services are to issue a report outlining recommendations and a technical prototype of a PAC PPS. Seagrave noted that the IMPACT Act does not specify a completion date for the project as the Secretary must first collect both quality measure data and standard patient assessment data for two years and analyze the data. AMRPA has learned that the Research Triangle Institute (RTI) has been retained to work on this project. Readers may recall that RTI was the contractor also on the Post-Acute Care Payment Reform Demonstration (PAC PRD).

Latesha Walker, RN, BSN, MS Latesha Walker, RN, BSN, MS, from CMS presented on behalf of the CMS Provider Compliance Group, which oversees Medicare fee-for-service contractors that conduct medical reviews of Medicare claims. The presentation began with an overview of the various Medicare contractors and their roles, which include Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractors (SMRCs), Recovery Audit Contractors (RACs), the Comprehensive Error Rate Testing (CERTs) Contractors and Zone/Unified Program Integrity Contractors (Z/UPICs). Walker then provided some updates on new initiatives, starting with the new Targeted Probe and Educate (TPE) Program, which is currently being operated by MACs. The TPE, Walker explained, is aimed at reducing the rate of claim denials and appeals by providing one-on-one help to providers. The program, which AMRPA has detailed in previous magazine articles, involves up to three rounds of claim reviews followed by education sessions to help improve provider performance.

Walker then moved on to further discuss CMS Patient’s Over Paperwork initiative. As Walker explained, the initiative is part of the Trump administration’s commitment to lower burden for providers and create efficiencies in the Medicare program. Walker went over a number of changes already enacted under Patients Over Paperwork, including clarification of signature requirements for documentations done by medical students and when using scribes, eliminating some proof of delivery requirements, and clarifying the three-hour therapy rule for Inpatient Rehabilitation Hospitals and Units.

Finally, Walker also discussed CMS efforts to lower paperwork burdens by improper provider-to-payer and provider-to-provider interoperability through enhanced use of electronic health records. Walker explained that these interoperability efforts include incorporating a documentation templates and requirements, as well as prior-authorization guidelines, in to record systems.

Chrissy Fowler The next speaker was Chrissy Fowler, Director of CMS’ Payment Accuracy and Reporting Group. Fowler presented on Improper Payment Rates and the Comprehensive Error Rate Testing (CERT) Program. Fowler began with background on the statutory basis of CMS improper payment rates, which she explained originated with the Improper Payments Information Act (IPIA) of 2002, and which was amended through several subsequent laws. These laws

AMRPA Magazine / May 2018 31

require CMS to identify Medicare programs that may be susceptible to significant improper payments, estimate the amount of improper payments in those programs, report the estimates to Congress and the public, and describe the actions the agency is taking to reduce improper payments.

Fowler then turned to the CERT Program, which is tasked with identifying improper payments in the Medicare program.

First, she explained that any payment that is either too high, too low, or should not have been paid at all, is considered a Medicare improper payment. Fowler also clarified that not all improper payments are considered fraud, and that the improper payment rate measures compliance with federal payment rules, and are not necessarily a measure of Medicare spending that should not have occurred in the first place.

Turning to the methodology and findings of the CERT program, Fowler said that the CERT review period runs July to June, so that, for example, claims from July 2016June 2017 are reported in the FY 2018 improper payment rate report. The CERT conducts a medical review of claims, and based on the CERT’s findings, calculates an improper payment rate based on its finding of the validity of those claims sampled. The CERT gives until October after the cutoff date of the sample time period and takes in to account any claims overturned on appeal through that time in to its calculation. The final improper payment rate findings are then reported in HHS’ annual financial report.

Further, Fowler explained that the CERT uses a unique breakdown of error categories to further examine the improper payment rates. For IRH/Us, the two main error categories are insufficient documentation and medical necessity. Medical necessity means that while the record contained complete documentation, the CERT did not find that it adequately indicated why the IRF stay was medically necessary. Insufficient documentation in the context of the CERT indicates that there was insufficient information to determine whether the claim was payable or that a specific documentation element that is required as a condition of payment is missing.

According to Fowler, in FY 2017, the national Improper Payment Rate for all providers was 9.51 percent for all Medicare payments, but 39.74 percent for IRH/Us. She explained that more than 90 percent of IRH/U Improper Payments were determined to be for medical necessity.

Tara McMullen, PhD Tara McMullen, PhD, provided status updates on CMS’ implementation activities with regard to the IMPACT Act and the standardization of patient assessment data elements across post-acute care (PAC) settings. After an overview on the IMPACT Act, she discussed the general timeline of activities for the coming year, which includes a national beta test that is underway through the summer of 2018. In the first half of 2018, CMS and its contractor on the national beta test, the RAND Corporation, is engaging with a broad range of PAC stakeholders to hear concerns and ideas for

32 AMRPA Magazine / May 2018

data element standardization. RAND will also hold targeted webinars in mid-2018 on special populations (e.g., pediatric populations) to inform future PAC standardization efforts.

McMullen noted that CMS’ alpha test on standardized data elements indicated that the majority of items were feasible to administer and showed adequate to excellent agreement between raters. Any data elements that did not fare in alpha 1 testing were modified and re-tested in alpha 2.

// McMullen noted that CMS’ alpha test on standardized data elements indicated that the majority of items were feasible to administer and showed adequate to excellent agreement between raters.

In late 2018, CMS plans to convene a forum on PAC data element standardization to the discuss findings of its pilot tests and stakeholder engagement activities with the public, answer questions, and garner feedback on candidate data elements. McMullen notes that the forum will provide an opportunity for open discussion with CMS leadership about data elements that may ultimately be incorporated as standardized assessment items across PAC settings.

Chris Grose, RN, and Charles Padgett, RN Chris Grose, RN, and Charles Padgett, RN, discussed the IRF Quality Reporting Program and public reporting of data on IRF Compare. Grose noted that, as in recent years, the IMPACT Act continues to guide CMS’ work on PAC quality measures. Immediately upcoming CMS quality events include an IRF QRP Training Event on May 9-10, 2018, in Baltimore. The training would cover the Drug Regimen Review measure and other items that are new on the IRF PAI version 2.0 effective October 2018.

CMS plans to overhaul and revamp the legacy QIES, CASPER and QIES Technical Support Office (QTSO) systems to a new iQIES platform. Padgett reported that CMS is currently in the development phase with a contractor and the work will continue through the next two years with prototyping, testing, and rollout. The goal is for the systems to become cloud-based and allow streamlined data submission, making the information and feedback reports more immediate and real-time. Additionally, iQIES would be able to support more than two user logins per facility. Padgett reported that at this time CMS anticipates being able to introduce iQIES in early 2019. She and Padgett then outlined the

various reports quality-related reports located in the QIES system and how providers can use them. She also stated CMS is well aware that PAC providers would like to have reports with patientlevel information for claims-based measures such as readmissions and Discharge to Community.

Grose encouraged attendees to reach out to CORMAC, CMS’ contractor for the PAC QRPs, to confirm that it has the correct point of contact information for their organization. This would ensure that CORMAC is able to contact the provider if there are any issues with quality reporting compliance, such as timely data submission throughout the calendar year. During the ensuring Q&A session, several AMRPA members asked CMS about granting greater flexibility with the IRF QRP to help providers meet the reporting requirement and not be subject to the two percent payment penalty. Padgett commented that the agency seeks to work with providers to reduce burden and improve program compliance.

Jim Mathews, PhD Jim Mathews, PhD, addressed MedPAC’s work in the areas of inpatient rehabilitation providers’ annual payment The latter portion of Mathews’ presentation focused on adequacy and the unified PAC PPS. Mathews explained the commission’s proposal for a unified PAC PPS. Pursuant that MedPAC has observed a significant variation in IRH/U to the IMPACT Act, MedPAC in 2016 issued a mandated margins but believes that additional analysis is necessary to report on the feasibility of a PAC PPS and recommended better understand the underlying causes for the variation. that a unified payment system could be implemented Specifically, the commission seeks to explore whether there earlier than anticipated and without functional status data is outsized variability I profitability at the IRF PPS at the case at its outset. (AMRPA has commented to MedPAC that mix level. He noted for instance that in the skilled nursing we do not support this approach). Mathews recognized facility (SNF) and home health payment systems, payments AMRPA’s ongoing dialogue with MedPAC regarding for therapy services are much more profitable than clinically the PAC PPS. He concluded his speech by outlining or medically complex patients, and hence MedPAC seeks to a comparison of MedPAC’s unified PAC PPS proposal understand if similar patterns exist in the IRF PPS. Mathews with AMRPA’s Continuing Care Hospital model: also reviewed the commission’s concerns with variability in patient assessments across IRH/ Us and again emphasized his desire MedPAC Unified PAC PPS Continuing Care Hospital (CCH) to better understand the possible underlying causes or drivers. He Site-neutral payment for SNF, IRF, Site-neutral payment for SNF, IRF, LTCH welcomed providers to meet with and LTCH, HHA services services educate MedPAC on these matters.

Stay-based payment, with Episode payment covering full stay + 30 adjustment for HH and 60-day HH days after discharge Mathews then turned to MedPAC’s episodes Payment adjusters based on patient work for the coming year. He

Adjusters based on patient characteristics developed using PAC-PRD explained that the commission characteristics developed using 8.9 data may apply an “efficient provider million PAC stays from 2013 construct” in its assessment of Adjustments for high-cost outliers, select IRH/Us payment adequacy in Adjustments for high-cost and high-cost patients the 2018-2019 cycle. Under this short-stay outlier patients using Providers could offer 1 level of care or framework, an efficient provider select high-cost services (e.g., 2+ levels within one facility; or 2+ levels is defined as one that is relatively ventilator) of care could be provided in different low cost and produces relatively

Providers could offer 1 level of care locations by single entity under single high quality patient outcomes. or 2+ levels within one facility payment bundle MedPAC has applied this framework to other provider settings to evaluate cost and performance, but not yet to IRH/Us.

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Joe Grogan Like other agency speakers, Joe Grogan emphasized the administration’s focus on streamlining and eliminating “byzantine” federal regulations to reduce burdens on health care providers. With the Spring Conference taking place only weeks after the release of the president’s FY 2019 Budget, Grogan commented on several proposals included there that are relevant to AMRPA members. Specifically, the budget proposals to reduce annual Medicare payments to PAC providers for FYs 2019 to 2023 and to implement a unified PAC PPS in FY 2024. Grogan said that the proposed unified payment system would build upon the goals of the IMPACT Act in that payments would be based on patient characteristics and clinical needs, and not the setting of care.

It would focus on patient care and rationalizing services to improve quality and patient outcomes. Separately, Grogan noted that it is “universally accepted” by the administration that Medicare denials and the appeals backlog are in need of serious reform. He then referenced proposals at the White House to use data to track provider behavior to address program integrity issues.

Rehabilitation Administrators’ Workshop – Tips (Secrets) to Managing a Successful Rehabilitation Hospital or Unit The Rehabilitation Administrators’ Workshop reviewed the fundamentals of key Medicare regulations that inpatient rehabilitation hospitals and units must meet:

Classification: What are the requirements to be considered an IRH/U vs. an acute care hospital and thereby be eligible to be paid under IRF PPS as opposed to the MS-DRGs? What is presumptive compliance under the 60 Percent Rule, much less what is the 60 Percent Rule?

Coverage: What are the medical necessity guidelines that define which patients may be treated in an IRH/U?

Payment: What are the basic building blocks of the IRF PPS? What should we do as providers to assure proper payment?

What are the quality metrics and how to meet them?

The sessions included examples of ways to comply as well as several lively discussions on how to operationalize the regulations. Attendees were split between new administrators and CEOs and many who were familiar with these requirements and came for a refresher course.

Medical Directors Symposium In addition to the Rehabilitation Administrator’s Workshop and the Leadership Forum, a record number of physicians attended AMRPA’s Medical Directors Symposium. Attendees heard from a number of their colleagues on topics aimed to improve the care delivered to their patients in inpatient rehabilitation hospitals and units. The specific topics included promoting the value of rehabilitation to valuable partners like managed care plans and accountable care organizations, proper documentation for medical necessity reviews, leadership through public policy advocacy, new program development experiences, as a well as an open forum to discuss emerging issues for rehabilitation physicians.

Conclusion Planning is underway for next year’s events. We encourage all AMRPA members, regardless of their level of Congressional advocacy experience, to become involved and serving as advocates for the field and the patients we treat. AMRPA works hard to ensure your success in this endeavor by providing training and resource documents, as well as scheduling Hill visits on your behalf. Stay connected with AMRPA for details to come on the 2019 Spring Conference and Congressional Fly-In!

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REGISTRATION OPENS IN MAY www.amrpa.org Early Bird Deadline June 30, 2018

Begin with our pre-conference IRF Boot Camp

Then enter our concurrent tracks: Business Operations & Leadership Development Clinical Care & Delivery: A Team Approach Regulatory, Legislative, and Accreditation Matters Marketing and Relationship Management & Other (to be determined by the abstracts you submitted!)

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2018 Final Health Insurance Exchanges Enrollment Report Released

In early April, the Centers for Medicare and Medicaid Services (CMS) released the Final Enrollment Report for the 2018 Health Insurance Exchanges. The report summarizes the enrollment activity in the individual Exchange plans during the open enrollment period for the 2018 plan year.

63 percent of consumers selected a silver plan, 29 percent selected bronze plans and 7 percent selected gold.

During open enrollment, the share of individuals 55 years of age and older enrolled in HealthCare.gov increased from 27 percent last year to 29 percent this year, while the share of young adults between the ages of 18 and 34 decreased slightly.

HealthCare.gov consumers who were not eligible for premium subsidies chose a plan on average that was 18 percent less expensive than those receiving subsidies.

Through the Exchanges, the percent of bronze plan selections was up 6 percentage points and the percent of silver plan selections was down 9 percentage points compared to last year.

Key findings:

Approximately 11.8 million consumers selected or were automatically re-enrolled in an exchange plan in the 50 states, plus the District of Columbia. This includes 8.7 million consumers in the 39 states using Healthcare. gov and 3 million consumers in state-based exchanges.

For the 2017 plan year, 12.2 million consumers enrolled during the open enrollment period.

Nearly three quarters of people who enrolled through the exchanges shopped for a policy versus letting their policy automatically renew. Among all consumers with a plan selection, 27 percent were new enrollees and 47 percent actively returned to select a plan.

The average unsubsidized 2018 monthly premium for HealthCare.gov consumers rose from $476 last year to $621 this year, an increase of 30 percent.

Approximately 83 percent of HealthCare.gov consumers nationwide had their premiums reduced by tax credits.

Among consumers who qualified for the credit, the average tax credit covered about 86 percent of the total premium, resulting in an average premium after tax credits of $89 per month. Across all consumers, the average premium was $153.

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In February, CMS issued a proposed rule that would broaden the appeal and availability of short-term, limited-duration insurance plans by extending the plans’ maximum duration of coverage from three months to 12 months. While this change may expand consumers’ options for insurance plans, short-term health plans are not subject to the same requirements as Affordable Care Act-compliant plans. For instance, short-terms plans are not required to offer Essential Health Benefits, which includes rehabilitative and habilitative services, and they can also exclude individuals with preexisting conditions.

The 2018 Health Insurance Exchanges Enrollment report is available on CMS website.

CMS Oversight of Medicare Beneficiary Data Security Needs Improvement, GAO Says

Highlights: »»

GAO concluded that CMS has not ensured that its contractors address data security weaknesses consistently.

»»

GAO also recommends that CMS establish an oversight program for qualified entities and researchers to assess whether they are implementing security controls as required.

The Government Accountability Office (GAO) conducted an examination of the Centers for Medicare and Medicaid (CMS) efforts to protect Medicare beneficiary data accessed by external entities and made recommendations for CMS to improve the security of Medicare beneficiaries’ health care data. The results were released in a recently published report, Electronic Health Information: CMS Oversight of Medicare Beneficiary Data Security Needs Improvement.

The breadth of beneficiary data collected and maintained by CMS and its partners makes the data especially useful for research and other purposes. However, the distributed nature of Medicare systems and networks, along with the fact that so many entities external to CMS are connected to them, increases the potential that unauthorized individuals could gain access to these systems and the extensive amount of Medicare beneficiary data they contain.

Thus, GAO sought to:

identify the major external entities that collect, store, and process Medicare fee-for-service beneficiary data;

determine whether requirements for the protection of Medicare beneficiary data align with federal guidance; and

assess CMS oversight of the implementation of those requirements.

GAO analyzed information about how external entities access data, reviewed CMS documentation on who they share data with, compared federal standards with CMS security requirements for external entities, and analyzed results of independent security reviews. GAO also interviewed CMS officials about their oversight activities.

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GAO’s Findings CMS Shares Medicare Beneficiary Data with Three Major Types of External Entities: 1. Medicare Administrative Contractors (MACs) that perform processing and distribution functions on behalf of CMS to support the payment of Medicare benefits for: ––

––

––

Medicare Part A (hospitals including inpatient rehabilitation hospitals and units, skilled nursing facilities, home health agencies, hospice, comprehensive outpatient rehabilitation facilities, critical access hospitals, rural health clinics, and federally qualified health centers).

Medicare Part B (physicians and non-physician practitioners, outpatient hospitals, parts of home health and hospice, and durable medical equipment, orthotics, and prosthetics suppliers); and Durable Medical Equipment (DME) (equipment and supplies ordered by a health care provider or every day and extended use, such as wheelchairs and portable oxygen equipment).

MACs process more than 1.2 billion claims for Medicare fee-for-service (FFS) beneficiaries annually that include beneficiaries’ protected health information, including individually identifiable health information, transmitted or maintained through CMS’s Virtual Data Centers (VDCs). To do so, they interact with more than 1.5 million health care providers enrolled in the Medicare FFS program. MACs also perform customer services for beneficiaries and providers, financial and debt management, audit and appeals functions, and medical reviews.

// GAO recommends that CMS develop additional guidance for researchers on implementing security controls required by CMS, consistently track results of independent assessments, and provide oversight of researchers and qualified entities. spending, past and present enrollment, and claims, which can benefit the public through improved delivery of healthcare services.

To obtain Medicare data from CMS, researchers must apply for access to a specific dataset, such as the Carrier file, which includes claims for services provided by physicians and other non-institutional providers. In the application, the researcher provides information explaining how the data are to be used and stored, and CMS reviews and approves (or denies) the application.

In order to collect, store and process information needed to process claims and make benefits payments on behalf of CMS, MACs connect directly to CMS’s VDCs through the CMSNet telecommunications network. The VDCs consists of two large data centers that are operated and managed by CMS that collectively serve as a platform for Medicare claims processing software systems. MACs use a combination of four CMS systems that operate within the VDCs to process claims. These systems and their functions are described in Table 2.

2. Research organizations (researchers) that use Medicare beneficiary data to study how health care services are provided to beneficiaries Research entities, such as universities and colleges, non-profit research institutes, and policy research organizations, use Medicare data to study how health care services are provided to beneficiaries. CMS offers researchers a broad range of data on the Medicare program to support research on current and future

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The researcher then enters a data use agreement with CMS for access to specific sets of Medicare beneficiary data, which are to be used only for stated research objectives. The data use agreement specifies which beneficiary data can be accessed, for what purpose, the duration of access, and data protection and

confidentiality requirements. Unless the agreement authorizes the release of the data in accordance with CMS policy, it is not to be released by the researcher.

Researchers can securely access beneficiary datasets through CMS’ Chronic Conditions Warehouse/Virtual Research Data Center (CCW/VRDC). Researchers can then conduct their analysis on the data using software tools provided by CMS within this secure environment.

As of October 2017, 195 research entities had received Medicare data.

3. Qualified public or private entities that use claims data to evaluate the performance of Medicare service providers and equipment suppliers Qualified entities use CMS claims data to assess the effectiveness of Medicare service providers and equipment suppliers. The Medicare Data Sharing for Performance Measurement Program, originally established to comply with the Patient Protection and Affordable Care Act (ACA), allows qualified entities to combine the Medicare data with claims data from sources other than Medicare to produce and publicly disseminate their findings. These include CMS-approved reports on provider and supplier performance with regard to measures of quality, efficiency, effectiveness, and resource use.

Like researchers, qualified entities have been approved to access data by CMS and must enter into a data use agreement with CMS. The agreement specifies which beneficiary data can be accessed, for what purpose, the duration of access, and data protection and confidentiality requirements. A separate agreement is required for each qualified entity’s activity. As of October 2017, 10 organizations had received Medicare data as a qualified entity. Each entity is responsible for analyzing and reporting on provider performance for one or more specific geographic area.

CMS Established Information Security Requirements that Align with Federal Guidance for Some, but Not All, External Entities

protecting the security of the shared data. However, the GAO found that CMS has not taken the necessary steps to ensure that beneficiary data is secure across all its platforms and user groups. MACs and qualified entities are given guidance that generally aligns with federal guidance and is based on an assessment of risks specific to CMS to ensure that appropriate controls have been included. However, CMS has not provided guidance to researchers on how to select and implement specific security controls and until CMS provides more comprehensive, risk based guidance on implementing security controls to all of its external partners, there is an increased risk that researchers will not fully implement appropriate protections for Medicare beneficiary data.

CMS Has Not Consistently Overseen the Implementation of Security Controls by External Entities The GAO found that CMS has developed and implemented an oversight program for the MACs’ implementation of security controls based on two types of annual independent assessments, which together help ensure that sufficient testing is being conducted each year. However, CMS has not ensured that the MACs track and remediate identified weaknesses consistently, including weaknesses that have been identified in recurring annual assessments. GAO also found that CMS has not established an oversight program for qualified entities and researchers to assess whether they are implementing security controls as they are required. Without more effective oversight programs in place, CMS lacks full assurance that external entities are appropriately implementing security protections for Medicare beneficiary data.

GAO’s Recommendations GAO recommends that CMS develop additional guidance for researchers on implementing security controls required by CMS, consistently track results of independent assessments, and provide oversight of researchers and qualified entities.

CMS concurred with GAO's three recommendations and described actions it has planned or taken to address them.

For the report Electronic Health Information: CMS Oversight of Medicare Beneficiary Data Security Needs Improvement, see GAO website.

CMS shares Medicare beneficiary data with multiple types of external entities and established basic requirements for

AMRPA Magazine / May 2018 39

NCHS Report Finds Differences Among Adult Day Service Centers,

by Ownership

References Lendon JP, Rome V. Variation in adult day services center participant characteristics, by center ownership: United States, 2016.

NCHS Data Brief, no 296. Hyattsville, MD: National Center for Health Statistics. 2018.

40 AMRPA Magazine / May 2018

The Centers for Disease Control and Prevention’s National Center for Healthcare Statistics (NCHS) published current national estimates of selected characteristics of participants in adult day services centers and compared these characteristics by center ownership type in a recent Data Brief, Variation in Adult Day Services Center Participant Characteristics, by Center Ownership: United States, 2016. The information contained in the data brief is based on data from the National Study of Long-term Care Providers (NSLTCP).

Adult day services centers are community-based centers that provide long-term care services, including structured activities, health monitoring, socialization and assistance with activities of daily living (ADLs) to adults with disabilities. Prior reports from NCHS has shown that an estimated 286,300 participants were enrolled in adult day services centers in the United States in 2016 and the percentage of forprofit adult day services centers has grown in recent years, from 40 percent in 2012 to 44 percent in 2014 and remaining stable at 45 percent in 2016. Although the 2016 NSLTCP includes an estimated 286,300 participants in 4,600 adult day services centers nationwide, the analyses in the report were based on 285,100 participants in adult day services centers for which ownership status was known.

// Prior reports from NCHS has shown that an estimated 286,300 participants were enrolled in adult day services centers in the United States in 2016 and the percentage of for-profit adult day services centers has grown in recent years, from 40 percent in 2012 to 44 percent in 2014 and remaining stable at 45 percent in 2016.

Findings:

The racial and ethnic composition of participants in adult day services centers varied by center ownership.

–– About 31 percent of participants in for-profit centers were non-Hispanic white, 29 percent were Hispanic, 24 percent were of other race and ethnicity, and 14 percent were non-Hispanic black. In nonprofit centers, participants were 54 percent non-Hispanic white, 15 percent Hispanic, 12 percent other race and ethnicity, and 17 percent non-Hispanic black.

Selected sociodemographic characteristics of participants in adult day service centers differed by center ownership.

–– A higher percentage of participants had some or all services paid by Medicaid in for-profit centers (73 percent) compared with participants in nonprofit centers (58 percent).

–– A higher percentage of participants in for-profit adult day services centers were aged 65 and over (65 percent) compared with nonprofit centers (60 percent).

–– For-profit adult day services centers had a slightly higher percentage of female participants (59 percent) compared with nonprofit centers (58 percent).

The prevalence of selected medical conditions among adult day services center participants differed by center ownership.

–– A higher percentage of participants in for-profit centers than in nonprofit centers had a diagnosis of diabetes (38 percent compared with 24 percent), depression (32 percent compared with 24 percent), heart disease (30 percent compared with 24 percent), and severe mental illness (11 percent compared with 8 percent).

–– A lower percentage of participants in for-profit centers than in nonprofit centers had a diagnosis of Alzheimer disease or other dementias (26 percent compared with 37 percent) and intellectual or developmental disability (21 percent compared with 36 percent).

Nonprofit adult day services centers had a higher percentage of participants needing assistance with selected activities of daily living (ADLs) than for-profit centers.

–– 41 percent of participants in nonprofit centers needing assistance with bathing compared with 37 percent of participants in for-profit centers.

–– A higher percentage of participants in nonprofit centers than in for-profit centers needed assistance with toileting (40 percent compared with 28 percent), dressing (39 percent compared with 34 percent), transferring in or out of a chair (30 percent compared with 27 percent), and eating (28 percent compared with 19 percent).

The prevalence of emergency department visits, discharges from overnight hospital stays, and falls among adult day services center participants differed by center ownership.

–– Nonprofit centers had a higher percentage of participants who had fallen in the last 90 days (10 percent) compared with for-profit centers (6 percent).

–– A slightly higher percentage of participants in nonprofit centers than in for-profit centers had emergency department visits (8 percent compared with 7 percent) and discharges from an overnight hospital stay (5 percent compared with 4 percent) in the last 90-day period.

AMRPA Magazine / May 2018 41

Latest Research Findings

New Cardiac Rehab Performance and Quality Measures Released A new set of performance and quality measures for cardiac rehabilitation patients was released by the American College of Cardiology Foundation (ACC) and the American Heart Association (AHA), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) in the Journal of the American College of Cardiology.

The new measure set includes six performance measures and three quality measures, and updates the original measure set released in 2007 and the 2010 focused update. The new measures build upon recent evidence-based clinical practice guidelines and scientific statements, and include feedback from peer review and public comments.

The performance measures, which target meaningful gaps in the quality of care and are typically based on Class I clinical practice guidelines, span the inpatient and outpatient care setting and the facility level and provider level to measure communication and care coordination as well as effective clinical care. They include:

Cardiac Rehab Patient Referral From an Inpatient Setting;

Exercise Training Referral for Heart Failure (HF) From Inpatient Setting;

Cardiac Rehab Patient Referral From an Outpatient Setting;

Exercise Training Referral for HF From Outpatient Setting;

Cardiac Rehab Enrollment–Claims Based; and

Cardiac Referral Enrollment–Registry/Electronic Health Records Based.

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New measures that may be useful but are not based on Class I clinical practice guidelines are included as quality measures.

These include:

Cardiac Rehab Time to Enrollment;

Cardiac Rehab Adherence (≥ 36 sessions); and

Cardiac Rehab Communication: Patient Enrollment, Adherence, and Clinical Outcomes.

“This update of cardiac rehab performance measures builds on the previous 2010 cardiac rehab referral measures by adding measures dealing with enrollment in and adherence

to a cardiac rehab program, as well as the coordination of care,” explains Randal J. Thomas, MD, MS, FACC, chair of the writing committee.

Moving forward, the authors explain that the new measures “will need to be tested and validated over time” and suggest additional areas for future research “that will potentially have an impact on cardiac rehab performance and quality measures.”

Source: New Cardiac Rehab Performance and Quality Measures Released

Study Examines Risk Factors for Post-stroke Cognitive Decline Stroke is one of the most feared cardiovascular complications, often leading to severe morbidity or mortality. A recent study published by the American College of Cardiology Foundation examined the impact that an incident stroke may have on a survivor’s cognitive function.

Of note for many cardiovascular specialists is the outside impact that cardioembolic strokes have on declines in global cognition and executive function. Therefore, efforts to prevent stroke, especially the use of anticoagulation in patients with atrial fibrillation, are extremely important. The study found that African Americans may experience larger declines in global and executive cognitive function and thus targeted efforts to reduce this health disparity is needed.

The authors followed 22,875 participants aged ≥45 years without baseline cognitive impairment from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, who enrolled between 2003 and 2007 through September 2015, to measure the effect of an incident stroke (n = 649) on the changes in cognitive function and cognitive impairment.

Findings The study found that incident stroke was associated with acute declines in global cognition, new learning, verbal memory, and executive function. Global function declines were greater in survivors who were black, men, and patients who suffered a cardioembolic stroke or a large artery stroke. Executive function declines were greater

in survivors who had less than a high school education.

Incident stroke did not have significant impact on new learning or verbal memory when adjusted for pre-stroke changes. Declines in global cognition were faster following a stroke for older survivors, those who resided outside the Stroke Belt, and those who survived a cardioembolic stroke. Declines in executive function were faster following a stroke for older survivors and those without hypertension.

// The study found that incident stroke was associated with acute declines in global cognition, new learning, verbal memory, and executive function.

The authors concluded that an incident stroke alters a patient’s cognitive trajectory, most significantly for survivors at older age and who suffered a cardioembolic stroke.

Source: American College of Cardiology Foundation

AMRPA Magazine / May 2018 43

AHRQ Study: Hospitals that Improved Profits Benefited More from Increased Revenues Than Cost Reductions Hospitals face financial pressure from decreased margins from Medicare and Medicaid and lower reimbursement from consolidating insurers. A recent study funded by the Agency for Healthcare Research and Quality (AHRQ) found that increased revenues had a greater impact than decreased costs among acute care hospitals that became more profitable between 2003 and 2013. The authors sought to determine whether hospitals that became more profitable increased revenues or decreased costs more and to examine characteristics associated with improved financial performance over time.

The study, published in the Journal of General Internal Medicine, examined 2,400 short-stay acute care hospitals in eight states between 2003 and 2013. The main measures were the change in clinical operating margin, change in revenues per bed, and change in expenses per bed between 2003 and 2013. Researchers concluded that more profitable hospitals increased per-bed revenues by an average $113,000 per year.

The same group of hospitals, meanwhile, reduced per-bed costs by about $10,000 per year.

Findings Researchers found that profit increases were driven largely by higher non-Medicare insurance payments rather than costreduction. The study found that hospitals that became more profitable had a larger magnitude of increases in revenue per bed (about $113,000 per year [95 percent confidence interval: $93,132 to $133,401]) than of decreases in costs per bed (about - $10,000 per year [95 percent confidence interval: - $28,956 to $9617]), largely driven by higher non-Medicare reimbursement. Hospitals that improved their margins were larger or joined a hospital system. Not-for-profit status was associated with increases in operating margin, while rural status and having a larger share of Medicare patients were associated with decreases

44 AMRPA Magazine / May 2018

in operating margin. There was no association between improved hospital profitability and changes in diagnosis related group (DRG) weight, in number of profitable services, or in payer mix. Hospitals that became more profitable were more likely to increase their admissions per bed per year.

The researchers concluded that the differential price increases have led to improved margins for some hospitals over time.

Where significant price increases are not possible, hospitals will have to become more efficient to maintain profitability.

The study was funded by AHRQ’s Comparative Health System Performance Initiative, which studies how health care delivery systems promote evidence-based practices and patient-centered outcomes research in delivering care.

Source: Agency for Healthcare Research and Quality

Medicare Discharges to SNFs Are Declining, Avalere Says

Highlights: »»

SNF utilization among Medicare beneficiaries has declined 15 percent between 2009 and 2016.

»»

Avalere finds that reductions in acute care hospital admissions are the primary drivers in the drop in SNF use.

Medicare beneficiaries are spending fewer days in skilled nursing facilities (SNFs) since 2009, according to latest findings from Avalere. The decline seems to be driven by changing patterns of inpatient hospital care, including fewer hospital inpatient admissions and more frequent observation stays, which result in fewer discharges to SNFs. Many patients are discharged to a post-acute care (PAC) providers such as inpatient rehabilitation hospitals and units (IRH/Us), long-term acute care hospitals (LTCHs), home health agencies (HHAs), and SNFs following hospitalizations for injury or illness. In post-acute care patients can continue their recovery or manage their illness.

Traditional, or fee-for-service (FFS), Medicare covers up to 100 days of eligible SNF care per beneficiary. In order to qualify for Medicare coverage of treatment in a SNF, Medicare requires that a patient must have at least three days of care in an inpatient hospital prior to being admitted to the SNF. If a patient is admitted to the hospital under observation status, rather than for a three-day inpatient stay, then they are ineligible for Medicare coverage of their SNF services following discharge.

Methods Avalere calculated national inpatient hospital discharges and observation stays, as well as SNF admissions and length-of-stay for 2009 through 2016. Avalere identified utilization using Medicare FFS claims submitted to the Centers for Medicare and Medicaid Services (CMS) from the CMS Standard Analytic Files (SAFs), which include 100 percent Medicare FFS Part A claims. In order to calculate per capita utilization, Avalere used CMS' enrollment file to calculate the number of beneficiaries enrolled in FFS at any point during the year.

AMRPA Magazine / May 2018 45

Findings

On a per capita basis, Medicare SNF utilization has declined every year since 2009. In 2009, there were 1,808 SNF days per 1,000 Medicare fee-for-service (FFS) beneficiaries. In 2016, there were 1,539 SNF stays per 1,000 beneficiaries, marking a 15 percent decline.

Since 2009, per capita hospital discharges have declined 17 percent, concurrent with an increase in observation stays. Observation patients, while treated in the hospital, are typically lower-acuity cases that require observation versus an inpatient admission before they are discharged.

The average SNF length of stay has remained steady at about 24 days.

programs may be driving more frequent use of observation stays. These factors, combined with the scrutiny on attenuated hospital inpatient stays, are driving the reduction in SNF use.

Furthermore, they note that the rise in HHA use was not the main driver for the decline in SNF use. Avalere experts did not observe shifts in the proportion of discharges to SNFs relative to home health and other PAC settings.

“The economics of post-acute care have been fundamentally changed as Medicare shifts its payment approach to capitation, bundles, and pay for value,” said Dan Mendelson, president at Avalere. “Fewer patients are being admitted to the hospital, as payers and risk-bearing providers seek to shift care to lower-cost settings.”

Avalere experts suggest that the dispersion of payment models that penalize readmissions, such as accountable care organizations, bundled payments and value-based purchasing

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EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE

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

46 AMRPA Magazine / May 2018

CMS Releases 2015 Medicare Current Beneficiary Survey Chartbook The Centers for Medicare and Medicaid Services (CMS) released updated data from the Medicare Current Beneficiary Survey (MCBS) in the 2015 MCBS Chartbook.

The Chartbook is an annual report on the current estimates on the health and health care characteristics for the Medicare population, and follows CMS' other publications in this series (The Health and Health Care of the Medicare Population, The Characteristics and Perceptions of the Medicare Population).

The MCBS covers a representative national sample of the Medicare population of beneficiaries aged 65 and over and those aged 64 and younger with disabilities in the United States and Puerto Rico. The MCBS primarily focuses on economic and beneficiary topics including health care use and health care access barriers, health care expenditures, and factors that affect health care utilization.

This article presents key data findings that may be of interest to AMRPA members.

Background The MCBS collects demographic characteristics, health status and functioning, access to care, insurance coverage and out of pocket expenses, financial resources, etc., in three data collection periods per year. Fieldwork for the first round of data collection began in September 1991 and has continued to provide data on the health status and health care costs and utilization of Medicare beneficiaries.

Exhibit 1.1. Demographic and Socioeconomic Characteristics of All Medicare Beneficiaries

The Chartbook consists of charts and tables that include estimates from the MCBS Survey File that contains data collected directly from respondents and is supplemented by administrative items plus facility (non-cost) information and Medicare Fee-for-Service (FFS) claims and the Cost Supplement File.

Type of Medicare Coverage and Dual Eligible Status of All Medicare Beneficiaries Exhibit 1.3 shows the type of Medicare coverage and dual eligible status of Medicare beneficiaries by age. For beneficiaries aged 65 and over, 68 percent had traditional FFS Medicare coverage while 32 percent were covered under Medicare Advantage. Less than half (46 percent) of beneficiaries aged 65 and over were dually eligible for both Medicare and Medicaid, and the proportion of beneficiaries with dual eligible status declined with age.

AMRPA Magazine / May 2018 47

Exhibit 1.3. Type of Medicare Coverage and Dual Eligible Status of All Medicare Beneficiaries by Age, 2015

Exhibit 2.1. Quality of Life Metrics Among All Medicare Beneficiaries, 2015

Self-reported health status and functional limitations of Medicare beneficiaries Exhibit 2.1 showed that 51 percent of beneficiaries selfreported that they had no functional limitations.

Exhibit 2.4. Self-Reported Chronic and Other Health Conditions Among All Medicare Beneficiaries, 2015

Self-reported chronic conditions and other common health conditions of Medicare beneficiaries The data in Exhibit 2.4 showed the highest self-reported health conditions were related to vision, hypertension, high cholesterol, and arthritis. Thirty-four percent of beneficiaries reported conditions related to cognitive impairment.

The 2015 MCBS Chartbook is available on CMS’ Medicare Current Beneficiary Survey website.

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MACPAC’s 2018 Report Outlines Ways to Improve Efficiencies in the Medicaid and CHIP Program

Highlights: »»

The share of Medicaid beneficiaries enrolled in any form of managed care grew from 58 percent in 2002 to 80 percent in 2015.

»»

In 2013, 11 percent of all freestanding rehabilitation hospitals received $9 million in DSH payments.

The Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) recently released its 2018 Report to Congress on Medicaid and CHIP with recommendations for program improvements. MACPAC is a nonpartisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services (HHS) and the states on a wide array of issues affecting Medicaid and CHIP. This article highlights findings and data tables that may be of interest to medical rehabilitation providers.

The report focused on three core areas as the commission considers opportunities for the programs to improve efficiency and impact in the delivery of critical health services to more than 80 million beneficiaries, including low-income individuals and individuals with disabilities.

1. Streamlining the Authorities States Can Use to Run Their Managed Care Programs States’ use of managed care to administer the Medicaid program has substantially increased over the years. According to MACPAC, the share of Medicaid beneficiaries enrolled in any form of managed care grew from 58 percent in 2002 to 80 percent in 2015. The share of Medicaid beneficiaries enrolled in comprehensive managed care was nearly 65 percent in 2015.

The Medicaid managed care program design has also evolved over this time, serving new groups of enrollees (e.g., low-income adults not eligible on the basis of disability) and covering new services, such as long-term services and supports.

In light of this growth in utilization, CMS issued a broad update to its regulatory framework for Medicaid managed care programs in 2016. The standards for

AMRPA Magazine / May 2018 49

states and plans with respect to network adequacy, rate development, quality assurance and performance monitoring, and beneficiary protections in enrollment, disenrollment, grievances and appeals, now apply to states and plans regardless of the authority used to implement the managed care program. The changes made in 2016 also placed new requirements on managed care programs that deliver longterm services and supports.

Today, enrollment of these beneficiary populations in comprehensive Medicaid managed care is now commonplace (Figure 1-2). This includes 27 percent of American Indian and Alaska Native Medicaid beneficiaries (about 235,000 beneficiaries); 62 percent of children enrolled in Medicaid based on a determination of a disability (about 829,000 beneficiaries); and 44 percent of children eligible for Medicaid on the basis of involvement in the child welfare system (about 406,000 beneficiaries).

In 2017, the commission began considering ways to streamline Medicaid managed care authorities, with the goal of reducing administrative burdens for states making delivery system choices while continuing to ensure adequate beneficiary protections.

After reviewing current law, the commission recommended three statutory changes that would streamline managed care authority in three different ways: 1. Congress should amend Section 1932(a)(2) to allow states to require all beneficiaries to enroll in Medicaid managed care programs under state plan authority.

2. Congress should extend approval and renewal periods for all Section 1915(b) waivers from two to five years.

3. Congress should revise Section 1915(c) waiver authority to permit Section 1915(c) waivers to waive freedom of choice and selective contracting.

The commission believes that allowing states a more streamlined mechanism to select managed care as their delivery system and to require beneficiaries to enroll in such systems is appropriate at this time, based on the experience that many states have with using Medicaid managed care programs for diverse beneficiary populations.

Mandatory Managed Care Enrollment Under current law, states cannot require the following beneficiaries to enroll in comprehensive managed care programs except with a waiver: individuals dually eligible for Medicaid and Medicare, American Indians and Alaska Natives, and children with special health care needs (including children eligible for Medicaid on the basis of disability or involvement with the child welfare system, or children receiving SSI). This policy reflects concerns common two decades ago that managed care arrangements for these groups should be entered into under special conditions; that is, waivers were seen as necessary to ensure adequate oversight that the needs of these beneficiaries were met.

50 AMRPA Magazine / May 2018

About 16 percent of Medicaid beneficiaries (about 1.8 million) who were dually eligible for Medicaid and Medicare were enrolled in comprehensive Medicaid managed care in 2013, including more than half of dually eligible beneficiaries enrolled in comprehensive managed care in Arizona, Hawaii, Minnesota, New Jersey and Tennessee. Seven states mandated partial-benefit dual-eligible enrollment in comprehensive Medicaid managed care plans in 2015.

MACPAC believes that, together, the two programs provide a comprehensive set of benefits, although coverage may vary by state.

2. Promoting Use of Telehealth as a Strategy for Addressing Access Barriers Because there are few federal requirements for Medicaid coverage of telehealth, states have flexibility in defining telehealth and establishing limitations on coverage. As a result, Medicaid policies for coverage of telehealth vary from state to state including in the following areas: modalities, specialties and services, providers authorized to deliver services, and sites of service. State telehealth coverage policies may differ for fee-for-service and managed care delivery systems.

Modalities In 2017, nearly all states and the District of Columbia provided some coverage of telehealth in Medicaid FFS; however, the definition of and scope of coverage of telehealth differs from

state to state. Some states narrowly define telehealth and limit coverage to live, two-way interactions or interactions using both audio and visual telecommunications, while other states use broader definitions or have established more inclusive policies. The most commonly covered form of telehealth is live video (synchronous telehealth), followed by remote patient monitoring (RPM) and “store-and-forward” technologies which transmit patient information through secure email transmission (Table 1).

Table 1. State coverage of telehealth modalities in Medicaid, October 2017

MACPAC recommends promoting the use of telehealth technology to improve states’ ability to increase access to services in rural areas as well as to highly specialized services where the supply of providers is limited. However, the commission notes that the evidence available to date on the effectiveness and outcomes of telehealth is mixed and few published studies address the effects of telehealth in Medicaid specifically. MACPAC notes that states seeking to implement or expand coverage of telehealth would likely benefit from additional research as well as from the experiences of other states.

3. Analysis of Disproportionate Share Hospital Allotments to States MACPAC is statutorily mandated to annually report on Medicaid disproportionate share hospital (DSH) allotments.

DSH hospitals receive DSH payments because they serve a high share of Medicaid-enrolled and low-income patients. At the national level, DSH spending accounted for 3.6 percent of total Medicaid benefit spending in FY 2016, an amount that has been relatively consistent since FY 2011.

In this year’s report, MACPAC states that it continues to find no meaningful relationship between states’ DHS allotments and the three factors that Congress has asked the commission to study:

the number of uninsured individuals;

the amounts and sources of hospitals’ uncompensated care costs; and

the number of hospitals with high levels of uncompensated care that also provide essential community services for low-income, uninsured, and vulnerable populations.

MACPAC also found that total hospital bad debt has fallen in the years since implementation of the coverage expansions under the Patient Protection and Affordable Care Act (ACA), especially in states that expanded Medicaid coverage:

Total hospital charity care and bad debt fell by $8.6 billion (23 percent) between 2013 and 2015, with the largest declines occurring in states that expanded Medicaid.

Medicaid shortfall increased by about $3.0 billion (23 percent) because of increased Medicaid enrollment.

The national uninsured rate declined by 0.3 percentage points between 2015 and 2016, resulting in a total decrease of about 4.6 percentage points from 2013 through 2016.

In 2015, deemed DSH hospitals continue to report lower aggregate operating margins than other hospitals (negative 0.3 percent for deemed DSH hospitals versus 1.6 percent for all hospitals). Total margins (which include revenue not directly related to patient care) were similar between deemed DSH hospitals (5.7 percent) and all hospitals (6.0 percent).

Aggregate operating and total margins for deemed DSH hospitals would have been about 4 percentage points lower without DSH payments.

Table 2. National number of uninsured persons and levels of uncompensated care, 2013-2016

Rehabilitation Hospitals and DSH Payments The share of hospitals that receive DSH payments varies widely by state. In 2013, 44 percent of U.S. hospitals received DSH payments (Table 2). Of the 257 freestanding rehabilitation hospitals, 29 hospitals, or 11 percent of all rehabilitation hospitals, received a total of $9 million in DSH payments.

States are allowed to make DSH payments to any hospital that has a Medicaid inpatient utilization rate of at least 1 percent, which is true of almost all U.S. hospitals. Public teaching hospitals in urban settings received the largest share of total DSH funding. Half of all rural hospitals also received DSH payments, including many critical access hospitals, which

AMRPA Magazine / May 2018 51

receive a special payment designation from Medicare because they are small and often the only provider in their geographic area.

Table 3. Distribution of DSH spending by hospital characteristics, SPRY 2013

For the complete report, see the MACPAC website.

52 AMRPA Magazine / May 2018

AMRPA Submits Comments to Congress on Increasing Consumer Transparency in Medicare Advantage Plans Editor’s Note: On March 23, 2018, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to members of Congress on improving access in Medicare Advantage (MA) plans in order to increase consumer transparency and access to clinically appropriate medical rehabilitation services at the point of service. The complete letter is printed below and also available at www.amrpa.org.

The Honorable Bill Cassidy U.S. Senate Washington, DC 20510

The Honorable Thomas Carper U.S. Senate Washington, DC 20510

The Honorable Michael Bennet U.S. Senate Washington, DC 20510

The Honorable Todd Young U.S. Senate Washington, DC 20510

The Honorable Chuck Grassley U.S. Senate Washington, DC 20510

The Honorable Claire McCaskill U.S. Senate Washington, DC 20510

Dear Senators Cassidy, Bennet, Grassley, Carper, Young and McCaskill: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we commend you for your bipartisan effort to increase health care price and information transparency. AMRPA shares your goal of increased transparency and greatly appreciates your solicitation of recommendations for ways to empower patients and caregivers to decide what medical care best fits their needs.

AMRPA is the national voluntary trade association representing more than 600 freestanding rehabilitation hospitals, rehabilitation units of general hospitals, and outpatient rehabilitation service providers (collectively referred to as inpatient rehabilitation facilities, or IRFs). Our members provide medical rehabilitation services in an array of health care settings, working to maximize patients’ health and functional skills so they can live as independently as possible by returning home, resuming work or pursuing an active retirement. In the IRF setting, AMRPA members provide intensive, comprehensive, hospital-based, rehabilitation therapy programs coupled with complex medical management of the patient. IRFs provide a multitude of therapy services including physical and occupational therapy, speech language pathology, and prosthetic/orthotic services.

Summary of Comments AMRPA is pleased to provide our recommendations for delivering health care in a more transparent manner that seeks to empower patients, and improve the quality of care while lowering overall costs. Our comments focus on improving access in Medicare Advantage (MA) plans to increase consumer transparency and access to clinically appropriate medical rehabilitation services at the point of service. Given that the MA program now covers one-third of all Medicare beneficiaries, it is increasingly important that the program be administered in a way that protects beneficiaries’ legal rights and guarantees their access to medically necessary care.

AMRPA asks that the following proposals be considered for inclusion in any legislation drafted as a result of this emerging transparency initiative:

Requiring disclosure of Medicare post-acute care coverage rules so beneficiaries receive adequate information about potential options upon admission to, and especially at discharge from, a short-term acute care hospital;

Restricting the use of proprietary decision tools unless they are shown to be fully consistent with Medicare coverage policy and clinical decision-making;

Requiring reporting of utilization, denial, and overturn rates for enrollee utilization of post-acute care;

AMRPA Magazine / May 2018 53

Auditing MA plan performance to ensure equal access to inpatient hospital rehabilitation across MA and fee-for-service Medicare beneficiaries, including by ensuring that IRFs are included in plans’ provider lists for determining network adequacy; and

Requiring that CMS develop better transparency means related to value of care and total episode of care comparative pricing information.

Background: MA Enrollees’ Challenges Accessing Clinically Appropriate Care AMRPA remains concerned that an increasing number of MA plans are circumventing Medicare coverage rules to deny beneficiaries access to medically necessary inpatient rehabilitation care. In fact, in its March 2017 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) found that MA enrollees were admitted to IRFs at approximately one-third the rate of Medicare fee-for-service beneficiaries in 2015. Ultimately, these coverage denials can be distilled down to a lack of transparency for the MA enrollee. Either their legal entitlement to inpatient rehabilitation care is withheld, and in many cases materially misrepresented, or they are allowed to be admitted to an IRF only to find out after discharge that the MA plan subsequently determined there was insufficient evidence of medical necessity. It is in this latter instance of retroactive denial, that the cost of post-acute care is hidden from the patient at the point of care.

Due to the uniquely intensive medical and rehabilitation services provided in an IRF, Medicare utilizes rigorous screening criteria and other regulatory requirements to ensure that each and every patient admitted to an IRF belongs there. CMS has developed detailed coverage regulations for Medicare IRF coverage. These coverage rules also apply to both Part A fee-for-service and Part C MA beneficiaries. Medicare regulations are clear that MA plans must provide “all Medicare-covered services.” These covered services include “all services that are covered by Part A,” which are the “basic benefits” available to MA enrollees. MA plans must comply with all Medicare coverage regulations and manuals. Medicare manuals are equally clear that an MA plan “must provide enrollees in that plan with all Original Medicare-covered services.” The relevant manual instructs that “[i]f the item or service is covered by Original Medicare under Part A or Part B, including Part B prescription drugs, then it must be offered.” Therefore, MA plans must determine IRF coverage using the Part A regulations at 42 C.F.R. § 412.622 and other applicable guidance.

Rather than following these Medicare IRF coverage criteria, many MA plans improperly apply private decision tools, such as Milliman and InterQual, to make coverage decisions that override clinical decision-making, both prospectively and retrospectively. These proprietary guidelines do not mirror Medicare coverage guidelines but are nevertheless being used to deny patients access to medically necessary and clinically appropriate medical rehabilitation services.

Moreover, MA plans often obfuscate their reasoning, refusing to share their placement assessments with providers, caregivers or others on the basis that the underlying decision tool is proprietary. This posture places patients in an unwinnable Catch-22 situation and flaunts one of the underlying premises for having uniform and transparent Medicare coverage policies that are available to all beneficiaries.

Consequently, many beneficiaries who qualify for inpatient hospital rehabilitation are diverted to less appropriate, lower-acuity settings, such as nursing homes and homecare, inevitably decreasing their prospects for full recovery. In doing so, MA plans fail to disclose the long-term costs associated with receiving inadequate post-acute care in the wrong setting – both in terms of diminished functional gain, lost productivity, and greater health care costs in the form of increased readmissions and emergency room visits, and more days in long-term care.

Disregard for MA Enrollee Appeal Rights Hospitalized MA enrollees are often precluded from exercising fundamental appeal rights in seeking clinically appropriate post-acute care. In many cases, enrollees are completely unaware of their rights to the same benefits as those enrolled in traditional Medicare, as well as their right to appeal a denial of a preauthorization for services in a particular setting. The most vulnerable beneficiaries are often at the greatest risk of being denied access to medically necessary rehabilitation services without knowledge of the decisions being made behind the scenes, and may lack the social or financial supports necessary to appeal without guidance.

The operating procedures of MA plans erect numerous barriers, bureaucratic processes and delays, as well as unreasonable paperwork demands which restrict access to higher-acuity post-acute care settings, such as IRFs, and limit opportunities for timely redeterminations. MA plans frequently deny a referral to an IRF but decline to provide a copy of the denial notice to the patient or caregiver, thereby hindering the possibility of a successful appeal.

Based on AMRPA members’ experiences, it is rare for an MA plan’s medical reviewer to have any expertise or even baseline knowledge in medical rehabilitation, and thus most reviewers are often unable to understand the patient’s rehabilitation needs. In contrast, IRFs are required to have a rehabilitation physician with specialized training in preadmission review to determine the appropriateness of a patient’s admission to an IRF, consistent with Medicare regulations. The aggregate effect of the high rate of initial denials and delays in preadmission determinations is that

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patients are stuck in the acute care setting for longer periods of time that are clinically appropriate, thereby exposing patients to increased health risks while imposing additional costs on the health care system.

Inadequate MA Data Impedes both Price and Information Transparency While existing Medicare data demonstrate that MA enrollees utilize post-acute care settings, such as IRFs, at a rate nearly one-third of those enrolled in the traditional fee-for-service program, empirical data underlying this disparity remains scarce. This has prompted increased calls for increased MA data transparency from medical experts pointing to the valuable insights into health care utilization, quality and cost that have been obtained from the availability of traditional fee-for-service Medicare data. For example, CMS’ former Chief Data Officer, Niall Brennan, recently noted that releasing MA claims data is long overdue, and that the availability of MA data constitutes a key component to continuing “recent advances made in transparency and open government.”

At a minimum, CMS should promptly institute reporting requirements for MA plans to begin recording this baseline data in uniform data sets and be required to report this information to CMS on a quarterly basis. Just as fee-for-service Medicare comparative information is now publicly available; the public should also be given timely access to summary MA data, as well as full data sets for appropriate purposes.

Moreover, CMS must gain a better understanding of the long-term cost and quality implications of this disparity in the utilization of post-acute care. In particular, the agency should work with plans to capture longer-term outcomes data based on an episode that extends two years beyond the initial acute care hospitalization. The most robust study on this topic, performed by Dobson, DaVanzo & Associates, found that Medicare beneficiaries admitted to IRFs for their immediate post-acute care had significantly better outcomes across a range of quality indicators compared to highly matched beneficiaries who received their immediate post-acute care in a skilled nursing facility (SNF). Over the twoyear study period, on average IRF patients:

Returned home from their initial stay two weeks earlier;

Remained home nearly two months longer;

Experienced fewer emergency visits;

Stayed alive nearly two months longer; and,

Had an eight percent lower all-cause mortality.

According to these findings, modestly higher spending on immediate post-acute care in the IRF setting was generally offset over the course of the two year period. Given the stark disparity in days in the community, IRFs are likely the more economical option if other payors—such as Medicaid—are taken into account. The availability of this information would empower consumers, reduce costs, increase quality and improve the system. Ultimately, clarifying Medicare rules for access to post-acute care is in everyone’s interest, including health care providers, MA plans, and patients, as well as the Medicare program itself.

Unit Pricing and the Total Episode of Care In the post-acute sector, there are substantive differences between different sites of service. Further, significant differences exist in unit pricing (e.g., the per diem payment model used in SNFs versus the discharge-based approach of the IRF prospective payment system (PPS)). The disparate payment systems today incentivize providers to discharge as early as possible from a setting with a discharge-based payment system to a setting with a per diem based payment system, and encourage inefficient use of each level of care.

Alternative payment models (APMs) may offer some potential to realign incentives, but early experience suggests APM participants could also be incentivized to discharge to per-diem based providers in the expectation of shorter length of stay (LOS). Regardless, it is important that Congress and CMS grapple with the value proposition that is obscured today because of these fundamental disparities across siloed payment systems. It is simply not good enough to talk about price transparency alone; rather there needs to be transparency around cost, quality and value across the total episode of care.

The Need for Greater Price Flexibility As we move toward episodic payment structures and proceed from testing to implementing promising APMs, providers with a discharge-based payment are disadvantaged. Medicare reimbursement for IRF services is incredibly rigid, with a fixed per-discharge payment based largely on factors outside of the IRF’s control (e.g., principal diagnosis in the preceding hospitalization). In contrast, other post-acute care providers such as SNFs and home health agencies (HHAs) have a greater degree of control over their Medicare charges, namely through decreasing lengths of stay under the per diem system.

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To facilitate greater price transparency and ultimately innovate care delivery, IRFs should be able to be responsive to such consumer-directed approaches and not be constrained by an inelastic Medicare fee structure, at least within the context of APMs. An increasing number of these models hold provider entities, such as acute care hospitals and/ or networks of downstream providers, responsible for post-acute spending. These models encourage post-acute care providers like IRFs to produce high-quality outcomes at a reduced cost. However, since Medicare rules do not allow IRFs to “charge less� in this context, existing bundling programs typically incentivize bundle-holders to steer patients away from receiving inpatient medical rehabilitation, even when it is imperative to their recovery. This runs counter to efforts to enhance transparency at the point of care, undermines patient-centric decision-making, and also runs afoul of Medicare rules. For IRFs to be able to compete alongside other providers in these APMs, willing participants must be permitted to charge a reduced amount, a per diem payment, or offer a discount from the IRF PPS rate. Despite waiving a myriad of other fundamental rules for APM participants, CMS has to date been unwilling to consider pricing flexibility; thus Congressional action is needed. Pricing flexibility, along with commensurate relief from the effects of regulations and policies that were designed around traditional prospective payment rates in the era of model testing will not only enhance transparency to patients, but will bring down the cost of care.

Once again, AMRPA greatly appreciates the opportunity to provide comments regarding your initiative to increase transparency in the health care system. If you have any questions regarding our concerns, please contact Carolyn Zollar at (202) 223-1920 or czollar@amrpa.org, or Martha Kendrick at (202) 887-4215 or mkendrick@akingump.com.

Sincerely,

Richard Kathrins, Ph.D. Chair, AMRPA Board of Directors President and CEO, Bacharach Institute for Rehabilitation

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To ensure that our members are active in shaping their federal representation in Congress, AMRPA is providing updates on upcoming elections as part of our civic engagement series. Below is information on primaries taking place in May and June, as well as directions to online resources where you can find more information on voting and your Congressional representatives.

The following 11 states will be holding primary elections in May: Indiana – May 8, 2018 Nine House seats are up for election, including seven incumbents and two vacant seats.

One seat in the Senate is up for election.

North Carolina – May 8, 2018 North Carolina has 13 House seats in the delegation. All incumbents are running for reelection.

There are no Senate seats up for election.

Ohio – May 8, 2018 Ohio has 16 House seats in the delegation, including 15 incumbents and one vacant seat.

There is one Senate seat up for election.

West Virginia – May 8, 2018 Three House seats are up for election, including two incumbents and one vacant seat.

There is one Senate seat up for election.

Idaho – May 15, 2018 Idaho has two House seats in the delegation, with one incumbent running for reelection and one vacant seat.

No Senate seats are up for election.

Nebraska – May 15, 2018 Nebraska has three House seats up for election; all incumbents are running for reelection.

There is one Senate seat up for election.

Oregon – May 15, 2018 Five House seats are up for election; all incumbents are running for reelection.

There are no Senate seats up for election.

Pennsylvania – May 15, 2018 Pennsylvania has 18 House seats in its delegation, with 12 incumbents running and six vacant seats.

There is one Senate seat up for election.

Arkansas – May 22, 2018 Arkansas has four House seats up for election; all incumbents are running for reelection.

No Senate seats are up for election.

Georgia – May 22, 2018 Georgia has 14 House seats in its delegation; all incumbents are running for reelection.

No Senate seats are up for election.

Kentucky – May 22, 2018 Six House seats are up for election; all incumbents are running for reelection.

No Senate seats are up for election.

The following 17 states will be holding primary elections in June: Alabama – June 5, 2018 Seven House seats are up for election. All incumbents are running for reelection.

There are no Senate seats up for election.

California – June 5, 2018 California has 53 House seats in the delegation, 51 incumbents and two open seats.

There is one Senate seat up for election.

Iowa – June 5, 2018 In Iowa, four House seats are up for election. All incumbents are on the ballot.

There are no Senate seats up for election.

AMRPA Magazine / May 2018 57

Montana – June 5, 2018

Colorado – June 26, 2018

Montana’s one House seat is up for election. The incumbent is running for reelection.

There is one Senate seat up for election.

Seven House seats are up for election in Colorado. Six incumbents and one open seat.

There are no Senate seats up for election.

New Jersey – June 5, 2018

Maryland – June 26, 2018

The New Jersey delegation consists of 12 House seats, with 10 incumbents and two open seats.

There is one Senate seat up for election.

Maryland has eight House seats up for election, with seven incumbents and one open seat.

There is one Senate seat up for election.

New Mexico – June 5, 2018

Mississippi – June 26, 2018

Three House seats are up for election in New Mexico. One incumbent and two open seats.

There is one Senate seat up for election.

Four House seats are up for election in Mississippi, three incumbents and one open seat.

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

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

There are no Senate seats up for election.

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

There is one Senate seat up for election.

Nevada – June 12, 2018 Nevada has four House seats up for election, two incumbents and two open seats.

There is one Senate seat up for election.

North Dakota – June 12, 2018 One open House seat is up for election in North Dakota.

There is one Senate seat up for election.

South Carolina – June 12, 2018 South Carolina has seven House seats up for election, Six incumbents and one open seat.

There are no Senate seats up for election.

Virginia – June 12, 2018

Oklahoma – June 26, 2018 Oklahoma has five House seats in its delegation. Four incumbents are running and there is one open seat.

There are no Senate seats up for election.

Utah – June 26, 2018 Utah has four House seats up for election; all incumbents are running for reelection.

There is one open Senate seat up for election.

Be sure to visit our website for more up-to-date election information. You can find the 2018 Congressional Elections page under the Advocacy tab on www.amrpa.org. If you have any questions or feedback, contact Catherine Beal at cbeal@amrpa.org or +1-202-223-1920.

For more information about your local representatives, visit the following websites: Find your House representative here: www.house.gov/ representatives/find-your-representative and Senators here: www.senate.gov/general/contact_information/senators_ cfm.cfm.

In Virginia, 11 House seats in the delegation, ten incumbents and one open seat.

There is one Senate seat up for election.

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

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