AMRPA Magazine May 2019 by AMRPA

May 2019 â&#x20AC;¢ Vol. 22, No.5

2019 FALL

2019

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

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May 2019 â&#x20AC;˘ Vol. 22, No. 5

The official publication of the American Medical Rehabilitation Providers Association (AMRPA) Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Director Kate Beller, JD AMRPA Executive Vice President for Government Relations and Policy Development Carolyn Zollar, MA, JD AMRPA Senior Policy Counsel Mimi Zhang AMRPA Director of Payment Innovation, Quality and Research Patricia Sullivan AMRPA Senior Editor Matthew Matyjek AMRPA Communications and Public Affairs Coordinator Brian McGowan AMRPA Design and Layout AMRPA Magazine, Volume 22, 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. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA.

Table of Contents Letter from the Chair

Legislative Update

What to Do If OIG Knocks on Your Door

How Can You Tell If You Are Ready for the New CMGs?

Providers Prepare for Ongoing and Potential Future Reforms to Telehealth Coverage & Payment Policy

MedPAC Issues Annual March Report; Recommends 5 Percent Update Reduction for IRFs and Examines PAC Issues as Well as Medicare Advantage

MedPAC Questions Future Use of Provider- Reported Function Data in Post-Acute Care

Attendees Hear from Policy Makers at 2019 AMRPA Leadership Forum

GAO Suggests CMS Revisit Documentation Requirements

Study Examines Trends in Lumbar Fusion Procedures and Costs

Environmental Scan Examines Primary Care-Based Efforts to Reduce Readmissions

CMS Issues Latest Enrollment and Costs for Dual Eligibles in Medicare and Medicaid

Supporting Post-Acute Care Transitions in Older Patients with Hip Fracture

CMS and CDC Develop Online Infection Prevention and Control Training Course

Latest Research Findings

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

AMRPA Magazine / May 2019

Letter from the Chair

Troubling Recommendations from the OIG A continued concern for our membership is the Department of Health and Human Services’ (HHS) Office of Inspector General’s (OIG’s) report on inpatient rehabilitation facilities (IRFs) (OIG, U.S. Department of Health and Human Services, 2018). Recommendations related to preauthorization and audits have significant implications for the patients we serve and can have wide-ranging implications for Medicare payment and coverage policies implemented by other HHS agencies.

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

A most troubling recommendation from the OIG report is that the Centers for Medicare and Medicaid Services (CMS) should pilot a preauthorization process for fee-for-service Medicare patients. AMRPA has already expressed concern about the reliability and methodology used by the OIG in this report (AMRPA, 2019). The OIG also recommends that CMS conduct additional audits of IRFs and consider implementing prior authorization for IRF services as a demonstration similar to the practices that Medicare Advantage Organizations (MAOs) employ. We all know from experience that prior authorization could delay and deny medically necessary care to patients. At the same time, the OIG itself recently concluded that prior authorization was abused by MAOs to deny medically necessary care (OIG, U.S. Department of Health and Human Services, 2018, page 12). With regard to the issue of additional audits, IRFs are already subject to numerous audits by Medicare Administrative Contractors and Supplemental Medical Review Contractors. AMRPA’s response to the OIG report was released in our Off the Record newsletter on January 14, 2019, (para 1) and is available on the AMRPA website. Most recently, we also expressed our concern about a provision in President Trump’s Fiscal Year (FY) 2020 Budget Proposal that would expand the use of prior authorization specifically for IRF services in the Medicare fee-for-service program (AMRPA, 2019). As noted above, the use of prior authorization in the Medicare Advantage program results in inappropriate denials and post-acute care placement decisions. Many of our patients who need IRF services are already being denied these services due to the use of tools such as prior authorization. Besides improper denials, the budget proposal would exacerbate this issue for fee-for-service beneficiaries, as these patients could be referred to inappropriate care setting and be subject to lengthy delays that could cause harm to the patients and their ability to attain optimal outcomes. If you haven’t done so by now, it is important to take a few minutes to reach out to your members of Congress to alert and educate them on the negative impact of prior authorizations for IRF services. AMRPA has previously sent out Grassroots Advocacy Alerts and discussed the issue on AMRPA Members-Only calls. Like all of our advocacy efforts, we need all of you to express the field’s concerns with a common voice. We are here to help if you need any assistance reaching out to your member of Congress or if you need talking points. Together we can make a difference.

References Office of the Inspector General, U.S. Department of Health and Human Services. (2018), Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements. (2018), (Report No. A-01-15-00500). https://oig.hhs.gov/oas/reports/region1/11500500.pdf Office of the Inspector General, U.S. Department of Health and Human Services. (2018), Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials (Report No. OEI-09-16-00410 ). oig.hhs.gov/oei/reports/oei-09-16-00410.asp American Medical Rehabilitation Providers Association. (2019, Jan 14). Off the Record- (AMRPA Responds to OIG Report). Retrieved from: https://amrpa.informz.net/ informzdataservice/onlineversion/pub/bWFpbGluZ0luc3RhbmNlSWQ9ODIzNjE4NA== American Medical Rehabilitation Providers Association. (2019, Mar 11). Off the Record – Special Edition (President Trump Releases Fiscal Year (FY) 2020 Budget Message and Priorities). Retrieved from: https://amrpa.informz.net/informzdataservice/onlineversion/pub/bWFpbGluZ0luc3RhbmNlSWQ9ODM4MTc0NQ==

AMRPA Magazine / May 2019

REGIONAL MEETING SERIES

Now Announcing AMRPAâ&#x20AC;&#x2122;s Regional Meeting Series!

Registration now open! For more information, visit the AMRPA website: amrpa.org/Education/Events/2019-Regional-Meeting-Series

AMRPA Magazine / May 2019

Legislative Update

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

Highlights: »»

»»

AMRPA is working with its members to educate their Congressional leaders about AMRPA’s concerns with a prior authorization program in Medicare. In an unexpected reversal on March 25, the Trump Administration’s Department of Justice filed a brief that now supports the Texas v. United States decision that the entire ACA should be struck down after the 2017 tax reform law effectively eliminated the individual mandate. The Administration previously argued that only the community rating and preexisting condition protection provisions in the law should fall. Reps. Olson (R-TX) and Schakowsky (D-IL) introduced the Preserving Rehabilitation Innovation Centers Act of 2019 (H.R. 1901), a companion bill to the previously introduced Senate version (S. 594) sponsored by Sens. Cassidy (R-LA) and Durbin (D-IL).

»»

Bipartisan, bicameral negotiations begin on a two-year Budget Caps deal, but President Trump is apparently content to let $126 billion in sequestration cuts take effect.

»»

The Office of Management and Budget (OMB) will now require federal regulators to submit nonbinding guidance documents for review.

AMRPA Magazine / May 2019

AMRPA Working with Lawmakers to Educate Congress About Prior Authorization Concerns We are asking AMRPA members for immediate help in reaching out to Members of Congress to alert and educate them on the negative impact of prior authorization for inpatient rehabilitation services and ask them to urge HHS to not move forward with a prior authorization program in Medicare. On March 18, 2019, the President’s Budget for Fiscal Year (FY) 2020 proposed expanding the use of prior authorization in Medicare, including for inpatient rehabilitation services. AMRPA is seeking to explain that prior authorization is inappropriate and unnecessary for hospital-level rehabilitation care given the rigorous pre-admission requirements. Prior authorization relegates medical judgment and supplants it with arbitrary guidelines, and delays recovery, denies access, and worsens outcomes, as evidenced by Medicare Advantage (MA). Your advocacy efforts are greatly needed! Timing is critical and we encourage you to reach out ASAP to your Member of Congress to make the connections and to ensure a timely impact on the regulatory process. Lawmakers Introduce the Preserving Rehabilitation Innovation Centers Act of 2019 On March 27, Representatives Pete Olson (R-TX) and Jan Schakowsky (D-IL) introduced the Preserving Rehabilitation Innovation Centers Act of 2019 (H.R. 1901), legislation “to recognize the contributions of rehabilitation innovation centers that serve a unique role in treating complex rehabilitation needs across the United States.” Senators Bill Cassidy (R-LA) and Dick Durbin (D-IL) have also introduced a companion bill in the Senate (S. 594). The legislation requires the Secretary of the Department of Health and Human Services (HHS) to make publically available on a website a list of all rehabilitation innovation centers. Additionally, HHS is required to publish an updated list on a website at least biennially. The bill as introduced defines “rehabilitation innovation centers” as facilities that, as of the date of enactment, are either not-for-profit or government-owned. The bill considers government-owned rehabilitation centers to be those that: (1) are classified as government-owned under the IRF Rate Setting File; (2) have at least one federal rehabilitation research and training designation for research projects on traumatic brain injury (TBI), spinal cord injury, or stroke rehabilitation from the National Institute on Disability, Independent Living, and Rehabilitation Research at the Department of Health and Human Services based on data submitted to the Secretary; (3) has a minimum Medicare estimated weight per discharge of 1.11144 for the most recent fiscal year for which information is available according to the IRF Rate Setting File or any successor regulations that contain the information; and (4) has a Medicare disproportionate share hospital (DSH) percentage of at least 0.6300 according to the IRF Rate Setting File for the IRF PPS for FY 2016. The legislation authorizes the Secretary of HHS to implement the law through program instructions or other means. The bill

requires that no later than March 15, 2021, and as determined necessary by the Medicare Payment Advisory Commission (MedPAC), the Commission submit a report to Congress that analyzes the three most recent years of cost report data for rehabilitation innovation centers and assesses the Medicare payment adequacy for the rehabilitation innovation centers. Any report must include recommendations for legislation and administrative action as determined appropriate by the Commission. Although AMRPA is grateful for the sponsors’ commitment to supporting research on traumatic brain injury (TBI), spinal cord injury, and stroke rehabilitation, there is concern with the narrow eligibility for being considered a RIC. AMRPA firmly believes that all rehabilitation hospitals should have the opportunity to meet the criteria for RICs, regardless of whether they are nonprofit or for-profit. Additionally, AMRPA questions the need for a Medicare Payment Advisory Commission (MedPAC) study which, if determined necessary, would not be useful in instructing policymakers about better supporting rehabilitation research, and proposes an alternative approach. AMRPA has sent a letter to Senators Cassidy and Durbin outlining multiple concerns. Negotiations to Raise the Budget Caps Continue On April 9, the House passed a Resolution by a vote of 219-201 (H.Res.294) that would set a $1.3 trillion ceiling for the FY 2020 spending bills. House progressives pushed back on a bill that was originally heading towards a floor vote that would have increased spending caps by $88 billion in FY 2020 for defense and non-defense spending. The Congressional Progressive Caucus did not believe that the measure included a large enough increase to domestic spending. On April 8, House Speaker Nancy Pelosi (D-CA) and Senate Majority Leader Mitch McConnell (R-KY) announced an agreement to begin discussions to negotiate a two-year deal in order to fend off $126 billion in automatic sequestration cuts on October 1. President Trump has publically berated Democrats for their funding plan and appears to support the impending $126 billion in sequestration cuts in non-defense spending. House Appropriations Chairwoman Nita Lowey (D-NY) will now use spending limits set out in H.Res.294 to fund the twelve annual spending bills. President Trump Now Supports Full ACA Repeal in Texas v. U.S.A. Case On March 25, the Department of Justice filed a brief in Texas v. United States supporting a federal district court decision that would overturn the entire ACA. Justice Reed O’Connor, citing a lack of severability in the law, ruled in December that the entire statute should be struck down after the 2017 tax reform law effectively eliminated the individual mandate. The Administration’s latest move was seen as a dramatic reversal, as the Justice Department had previously argued that only the community rating and pre-existing condition protection provisions in the law should fall. If the 5th Circuit Court of Appeals affirms the district court decision, the case will likely head to the Supreme Court. Repeal of the entire ACA would have wide-ranging impacts beyond the health insurance markets, including elimination of the Center for Medicare and Medicaid Innovation’s authority and funding. It was announced on April

10 that the U.S. Court of Appeals for the 5th Circuit granted a motion to hold a hearing on the case in July. Health Care Cost Transparency Legislation Moving Legislation around drug pricing issues has started to advance in the House. The House Energy and Commerce Committee’s Health Subcommittee marked up six drug pricing bills on March 27 aimed at promoting generic and biosimilar competition. While most of the bills had bipartisan support, there was disagreement over the CREATES Act (H.R. 985), which would improve access to brands’ equivalent samples, and legislation to target so-called “pay-for-delay” deals. Lawmakers on both sides were able to resolve their differences before a Full Committee markup on April 3, and the CREATES Act along with five other drug pricing bills were approved and now head to the House floor. On April 9, the House Ways and Means Committee advanced H.R. 2113, the Prescription Drug Sunshine, Transparency, Accountability and Reporting (STAR) Act. The bipartisan bill would require drug manufacturers to be more transparent with regard to drug price increases and require increased clarity from manufacturers and pharmacy benefit managers (PBMs) on rebates. In the Senate, the Finance Committee held a hearing on April 9 to hear from PBMs on their role in the drug supply chain. Committee Members pushed for increased transparency along the drug supply chain. Lawmakers also continue to mull over “surprise billing” legislation to protect patients against “balance billing,” where a patient unexpectedly receives a medical bill from a provider that was out-of-network after seeking care at an in-network facility. In the Senate, a bipartisan group of Senators, led by Sen. Bill Cassidy (R-LA) and Sen. Maggie Hassan (D-NH), are working together to introduce legislation this spring. Senate HELP Committee staff have been engaging with the Administration on the balance billing issue and legislation may move as part of a larger package to address health care costs. On April 2, the House Education and Labor Subcommittee on Health, Employment, Labor, and Pensions held a hearing titled, “Examining Surprise Billing: Protecting Patients from Financial Pain.” Witnesses recommended prohibiting balance billing for emergency services provided at an out-of-network facility, for treatment by an out-of-network provider at an in-network facility, as well as out-of-network ambulance and air ambulance providers. CMS Finalizes MA Plan Policies for 2020 On April 1, the Centers for Medicare and Medicaid Services (CMS) announced Calendar Year (CY) 2020 Medicare Advantage (MA) Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. MA rates will increase on average from 1.59 percent in 2019 to 2.53 percent in 2020. CMS continues to rely on encounter data to set payments and will up the share of the MA formula that comes from encounter data from 25 percent to 50 percent. The agency also will allow plans more flexibility to offer non-health care benefits, such as transportation and meals, to beneficiaries with chronic conditions. On April 5, CMS released a Final Rule, making policy and technical changes to the Medicare Advantage (MA) and

AMRPA Magazine / May 2019

Medicare Prescription Drug Benefit (Part D) program for 2020 and 2021. The Final Rule allows MA beneficiaries to access telehealth as a basic benefit, starting in plan year 2020, as required by the Bipartisan Budget Act of 2018.

inpatient and 3 outpatient. CMS is finalizing the selection of new clinical episodes for Model Year 3, which will include outpatient Total Knee Arthroplasty (TKA). ***

OMB Provided Authority to Review Nonbinding Regulatory Guidance Documents On April 12, Office of Management and Budget (OMB) Acting Director Russell Vought sent a memorandum to federal agencies, directing them to send guidance materials to the Office of Information and Regulatory Affairs (OIRA) for review beginning May 11, 2019. Seen by some as a maneuver to tighten control over regulators, Administration officials maintain that the memo provides additional clarification on what types of guidance documents that may have a significant economic impact are covered under the Congressional Review Act (CRA) statute. The memo confirms that Congress has the authority to strike down “major” guidance that reaches a certain threshold under the CRA. BPCI Advanced Application Period Announced CMS announced that the application period for the second cohort of participants in the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model will open in April 2019. Model Year 3 will start on January 1, 2020. Currently, BPCI Advanced consists of 32 bundled clinical episodes - 29

AMRPA Magazine / May 2019

As referenced, AMRPA continues to work hard in Washington, D.C. to educate lawmakers on the negative effects that the President’s FY 2020 Budget proposal to expand the use of prior authorization in Medicare, including for inpatient rehabilitation services, will have on patients that need medically necessary rehabilitative care. We encourage you to reach out ASAP to your Members of Congress to ensure your Representatives understand the threat prior authorization presents and to assist us in having a timely impact on the regulatory process. We would be happy to provide any additional information and assistance in reaching out to your Members of Congress. We greatly appreciate your time and willingness to help AMPRA communicate the important message about how this proposed FY 2020 Budget policy will significantly impact access to vital inpatient rehabilitation services, and will ultimately impair the rehabilitating future of beneficiaries recovering from serious injury or illness.

2019 FALL

2019

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

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

Abstract Deadline: May 13, 2019

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

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

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

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AMRPA Magazine / May 2019

What to Do If OIG Knocks on Your Door

This monthly article frequently touches on issues related to audits of inpatient rehabilitation hospitals and units (IRH/Us) by various contractors under the Centers for Medicare and Medicaid Services (CMS). However, CMS’ contractors are not the only auditors to worry about. The Department of Health and Human Services’ Office of Inspector General (OIG) also presents a significant audit concern.

Peter W. Thomas, Principal, The Powers Law Firm

Christina A. Hughes Counsel, The Powers Law Firm

OIG has primary responsibility for overseeing program integrity under all Health and Human Services programs, including Medicare and Medicaid. Specific topics of interest are generally set forth in OIG’s Work Plan which is annually published. For a number of years, OIG included IRH/U services on its Work Plan. The targeted work on this topic concluded in October of last year when OIG issued its report, Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements. As previously reported, this audit report was highly unfavorable to IRH/ Us, alleging an estimated $5.7 billion in Medicare overpayments in 2013 to IRH/Us for care that was not reasonable and necessary. This represents an astounding 84 percent error rate. In addition to its industry-wide review, in recent years, OIG has also included IRH/Us (both units and freestanding hospitals) in facility-specific audits. The results of these audits generally have been unfavorable to IRH/Us, although with error rates that have not been as severe. Given the results of the Work Plan audit and the individual facility audits, it is highly likely that OIG will continue to audit IRH/Us in the future, potentially in a new Work Plan audit with more recent dates of service, but almost certainly in future audits of individual providers. What Should an IRH/U Expect in an OIG Audit? OIG has relatively broad authority to perform audits under its mission to protect program integrity. Unlike the audits performed by CMS contractors, there are few publicly available guidelines or requirements on how such audits are to be conducted. This gives OIG a fair amount of latitude. Over time, OIG has developed a basic pattern for carrying out audits, though there can be some variation, depending on the nature of the audit and the OIG personnel involved. Most audits begin with some notification to the provider that OIG intends to audit claims for a certain time period, followed by a formal entrance conference where the scope of the audit is laid out in more detail. Throughout the process, providers will often be given very little information as to why they were selected for audit. Sometimes providers are selected after being referred for investigation by a CMS contractor; more often it seems that OIG and CMS identify audit targets through data analysis. It does not really matter how a provider is targeted, however, given OIG’s broad discretion. Nonetheless, because of the frequent reliance on data analysis, OIG does tend to target

10 AMRPA Magazine / May 2019

providers that stand out from their peers in some way, whether in outcomes from previous CMS audits or even just routine responses to required reports such as PEPPER reports. Time periods covered by audits frequently span one or two years, though they have occasionally encompassed a greater range. Depending on the nature of the provider, the scope of claims to be reviewed can be very narrow (i.e., only IRH/U claims) or cover a wide range of claims (i.e., outpatient and inpatient services, and multiple types of claims within each category). Either at the entrance conference or shortly thereafter, OIG will present the provider with a list of claims selected for audit. The provider then has a defined period of time to produce the requested medical records for review. Sometimes the list of claims includes both a main set of claims as well as a set of claims to be held in reserve for review if certain claims in the main set are rejected from the sample for some reason. More often, if claims from the first request are rejected, either OIG makes do with the remaining claims or OIG makes a secondary request for additional claims. After receiving the requested records, OIG will eventually produce preliminary results for review by the provider. Generally the provider is permitted at least one opportunity to respond to the preliminary results, and sometimes multiple opportunities for input or a back-and-forth dialogue occurs. The provider is usually given very little information about how the review of the claims was actually conducted, but OIG almost always relies on an outside contractor to handle medical necessity reviews. These contractors are likely CMS contractors as well—both C2C Solutions and MAXIMUS Federal Services (the current Qualified Independent Contractor) have served as contractors for OIG on audits in the past. At the time of releasing its preliminary results to the provider, OIG will usually inform the provider whether it intends to use extrapolation to calculate an estimated overpayment amount. OIG’s use of extrapolation has significantly increased over the past five years, with many of the recent audit reports involving at least some level of estimated overpayments. Unfortunately, OIG is not bound by the same limitations as CMS contractors in utilizing extrapolation. However, OIG should provide the working materials related to its sampling and extrapolation upon the provider’s request so that the methodology may be examined and potentially challenged. Depending on the nature of the audit and the preliminary findings, OIG may request that the provider complete an Internal Controls Questionnaire (ICQ). Each ICQ is different because it is tailored to the specific findings of the relevant audit. However, ICQs focus on the existing steps a provider has taken to be in compliance with Medicare requirements and what additional steps the provider intends to take to rectify any weaknesses identified by the audit. After consideration of any responses by the provider to the preliminary results or ICQ, an exit conference will be scheduled. The topics to be covered at the conference are subject to the preferences of the OIG staff involved in the audit. Exit conferences can be very brief and limited to mere formalities, or

// The presence of an inpatient rehabilitation unit can cause an acute care hospital to stand out from its peers during data analysis, depending on how the data mining is pursued, and freestanding rehabilitation hospitals are likely to be under additional scrutiny following the outcome of OIG’s industry-wide review. they can be more substantive and touch upon outstanding issues between OIG and the provider. Once the exit conference is held, OIG will issue a draft report and give the provider an opportunity to submit comments. The final report is subsequently issued (and published publicly on OIG’s website) and includes OIG’s summary and response to the audited provider’s comments as well as the full submission from the provider (redacted as needed). Best Practices for Providers Under an OIG Audit While it is difficult for IRH/Us to immunize themselves against OIG audits, there are some steps providers can take to streamline the audit process once it begins. First and foremost, the IRH/U should develop a specific point of contact with the OIG— meaning a person at the provider who will serve as the point person in communicating with OIG and an OIG staff member who is the primary contact. A limited set of additional personnel who are to be copied on any communication should also be developed as necessary, but communication to and from OIG should always flow through the IRH/U’s designated contact. Note that it is not necessary for the IRH/U’s designated contact to be an attorney but this person should be conscientious and reliable. The provider’s general counsel should be involved as soon as OIG establishes contact with the IRH/U but serious consideration should also be given to engaging outside counsel with expertise in Medicare audits and appeals. Bringing in such counsel early on can streamline the process substantially, and avoid missed opportunities to work with OIG on reaching the most favorable conclusion possible. Later, once the preliminary results are issued, it will be necessary to also consider whether independent medical and/or statistical experts should be consulted and added to the IRH/U’s OIG response team.

AMRPA Magazine / May 2019 11

After receiving the list of claims to be reviewed, the provider should carefully examine each claim on the list. Careful consideration should be given to details such as whether the selected claim has previously been audited by a CMS contractor or whether the claim is an outlier in some way. After receiving the preliminary results, it is important that the provider hold off on repaying any claims, even if it determines that it agrees with the denial. Repaying claims prior to the conclusion of the audit can cause undue confusion later. Next Steps As might be expected, most OIG audits indicate a much higher level of payment error than is accepted by the audited provider. This generally means that, at the conclusion of the audit, the provider is faced with the need to appeal OIG-denied claims and potentially to get ahead of negative press attention, especially if extrapolation is used to demand a multimillion dollar repayment. Providers should keep the potential for appeal in mind, and can even use the opportunity to respond to OIG’s preliminary findings and draft report to begin crafting the language for the appeals. Providers may also want to prepare for handling media at the time of the OIG’s release of the audit report. Once the OIG report is made public, the provider’s Medicare Administrative Contractor will likely issue a demand letter for some or all of the identified overpayment. The amount may differ from the amount in the audit report, and providers should be sure they understand why the difference exists. Where appropriate, the rebuttal process (which is separate from the appeals process) can be used to try to address miscalculations in the overpayment amount. This is also generally the ideal opportunity to repay any claims that the provider agrees were in error. Generally, the provider should strongly consider appealing any and all claims that it disputes OIG’s findings. This is

12 AMRPA Magazine / May 2019

especially important when extrapolation is used to estimate an overpayment amount—even small claims can have a significant impact when extrapolated. Extrapolations also trigger special considerations in appealing, since all the claims involved in the sample and estimate must be appealed together. As mentioned in previous articles, however, challenging an extrapolation can be daunting, so careful development of the potential arguments against the extrapolation needs to occur. Finally, in the event that a provider agrees with some of the conclusions in OIG’s audit report, the provider may find itself in a position where further self-auditing must also be carried out in order to comply with the 60-Day Report and Repay requirement. A very fact-specific inquiry into the nature of the payment error and the reason why the provider conceded the overpayment determination should be made to determine whether further internal investigation is warranted. Conclusion IRH/Us are a favorite target for many auditors because they have relatively big dollar claims, and OIG appears to be no exception. The presence of an inpatient rehabilitation unit can cause an acute care hospital to stand out from its peers during data analysis, depending on how the data mining is pursued, and freestanding rehabilitation hospitals are likely to be under additional scrutiny following the outcome of OIG’s industry-wide review. When faced with an OIG audit, providers should carefully consider all options available to contest negative findings and zealously defend their rights, utilizing all available resources, especially in light of OIG’s reasonably standardized process that makes past experience in OIG audits very instructive. Given OIG’s penchant for extrapolation and the current climate favoring fraud and abuse enforcement actions, the potential consequences are too great for complacency.

How Can You Tell If You Are Ready for the New CMGs?

You are already well aware that this summer will be a time of change as we begin implementing sections GG and H items from the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) as the basis for inpatient rehabilitation’s Medicare payments. I hope that you have an implementation plan in place and are beginning to work on your transition. In this article, I point out the eRehabData® analytical tools that will help you when the new case mix groups are in place.

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

// While negative numbers are eye-opening, observing a positive reimbursement difference does not mean that you are in the clear or that no further action is required.

The first area that deserves your attention is the eRehabData® facility report. When the proposed rule came out last year, eRehabData® modeled the changes so our subscribers would have an idea of what was coming their way. The 2020 Proposed Grouper Model indicates what your anticipated case mix index would be based on the patients admitted in the time period you designate. The difference in average expected reimbursement highlights whether you will earn more or less money on average. If you see a negative number, that is an indication that your data collection process will not result in the same average reimbursement that you have now. While negative numbers are eye-opening, observing a positive reimbursement difference does not mean that you are in the clear or that no further action is required. All providers will need to alter the way they think about the timing and assignment of the section GG and H items. There are a few other tips in the reports that can help you ensure reimbursement that matches the current burden of care for your patients. The Functional Scoring Congruency percentage is a measure of how likely your section GG scores are to be similar to your FIM™ scores. The higher the percentage, the more negative reimbursement difference you can expect. A lower congruency percentage may indicate that you are ineffective at capturing your burden of care in the section GG and H items while you are doing a good job of capturing burden of care scores using the FIM™ instrument. Pay attention to the breakdown of scores and totals in self-care and mobility. Identify the items that you are scoring higher on average than the nation or region. This provides an idea of where your approach to scoring may need to be examined. Next, look at the function scoring comparison graph that shows facility scores compared to weighted national or regional scores. The graph will show your difference in admission scores, discharge scores and the change from admission to discharge scores. We continue to struggle with the definitions the Centers for Medicare and Medicaid Services (CMS) published and the guidance offered in the CMS questions and answers. Per CMS, we have three days to obtain a score of each of the section GG items. Further, CMS indicated that the scores that we report on the IRF-PAI should be a reflection of the patient’s burden of care prior to patients benefiting from therapeutic intervention.

AMRPA Magazine / May 2019 13

While maintaining safety, we should be assessing the patient in the manner that they complete the activity based on their prior level of function. To me, that indicates that we should be recording the score for each section GG item during the first assessment of that item. For eating, that would mean the first meal. For transfers, that would mean the initial transfer. If strategies or adaptive devices are offered in that episode, then therapeutic intervention has been offered. Subsequent meals or transfers would be completed differently and the scores would not be eligible for use on the IRF-PAI according to the guidance provided by CMS. If the breakdown of your section GG scores indicates higher numbers than the nation and region, determine whether you are capturing scores in accordance with the intent laid out by CMS.

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Another analytical tool that we have available is an indicator in the patient’s record that reflects a significant difference between the FIM™ scores and the section GG and H scores. On a patient level, this can indicate where nursing scores or a different approach to assessment resulted in less of a burden of care for the patient than the FIM™ scores did. On your summer list of things to do, include a review of your documentation to ensure that your data collection is optimal, include nurses in the initial assessments, and educate therapists and nurses on conducting assessments free of therapeutic intervention. Start early in order to test your tools and the impact of your education. Rely on the eRehabData® analytical tools to highlight opportunities for improvement.

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16 AMRPA Magazine / May 2019

Providers Prepare for Ongoing and Potential Future Reforms to Telehealth Coverage & Payment Policy In recent weeks, both Congress and the Trump administration have increased their focus on telehealth issues, with the Centers for Medicare and Medicaid Services (CMS) finalizing rules to expand the use of telehealth in Medicare Advantage and the Congressional Telehealth Caucus seeking feedback from the industry on potential telehealth and remote patient monitoring-focused legislation.

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

First, on April 5, 2019, CMS issued a final rule titled, Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021. The wide-ranging rule included numerous provisions related to telehealth benefits in the Medicare Advantage (MA) program, reflecting new authorities provided to CMS under the Bipartisan Budget Act of 2018. Per CMS, the telehealth-related changes are part of the agency’s efforts to “to modernize the Medicare Advantage and Part D programs, unleash innovation and drive competition to improve quality among private Medicare health and drug plans.” The Bipartisan Budget Act of 2018 granted MA plans with new authority to include “additional telehealth benefits” – benefits not covered in fee-for-service (FFS) Medicare – in their bids for basic Medicare benefits. In line with this statutory change, the April 5 rule allows MA plans to cover telehealth services from a beneficiary’s home, regardless of whether the beneficiary resides in a rural or urban area (effective CY 2020). Under prior policy, MA enrollees were required to travel to health facilities to receive covered telehealth services unless they met certain residency restrictions (for example, living in a rural area). The rule also includes a number of payment-related changes, granting MA plans with new flexibility in how they pay for coverage of telehealth benefits to meet the needs of their enrollees. CMS states that the goal of the rule is to make it “more likely that [MA] plans will offer the additional telehealth benefits outside of supplemental benefits, expanding patients’ access to telehealth services from more providers and in more parts of the country than before, whether they live in rural or urban areas.” The April 5 rule follows a series of regulatory measures by CMS focused on telehealth in recent months. For example, in the CY 2019 Medicare Physician Fee Schedule final rule, CMS finalized its proposals to add HCPCS codes G0513 and G0514 (Prolonged preventive service[s]) to the list of covered telehealth services. In the same rule, CMS finalized policies to expand telehealth services for beneficiaries with End-Stage Renal Disease (ESRD) receiving home dialysis and beneficiaries with acute stroke via changes to originating site requirements and geographic exemptions, effective January 1, 2019. While CMS has been active with respect to telehealth policy on the regulatory side, a number of telehealth-related bills have been introduced to date in the 116th Congress. Examples of legislation introduced in recent weeks include bills that would expand the types of services that could be provided via telehealth in the Medicare program – such

AMRPA Magazine / May 2019 17

as certain mental health services – as well as a bill requiring that the Center for Medicare and Medicaid Innovation (CMMI) test the effect of including telehealth services in its Medicare-focused demonstrations. Most recently, in late March, the bipartisan, bicameral members of the Congressional Telehealth Caucus issued a Request for Information (RFI) seeking input on issues related to telehealth and remote patient monitoring. The members note that they are looking to advance a comprehensive telehealth-focused legislative package this Congress, and seek recommendations from providers and other stakeholders on ways to: (1) expand access to telehealth and remote patient monitoring, especially in rural or underserved parts of the country; (2) improve patient outcomes, whether by expanding access to specialists or other providers or easing the day-to-day patient experience; (3) encourage easier and expanded use of existing telehealth and remote monitoring technologies; and (4) reduce healthcare costs for both patients and federal programs, such as Medicare. The American Medical Rehabilitation Providers Association (AMRPA) submitted comments for the caucus’ consideration, asking the members to consider the following: Directing CMS to conduct a demonstration that tests expanding the types of therapy that can be delivered via telehealth in the Medicare program; Expanding beneficiary access to certain critical services – such as mental health and psychiatric care – delivered by telehealth in all areas of the country; and Ensuring CMS has the authority and resources to continue to expand the use of remote patient monitoring (RPM) and incentivize RPM utilization by Medicare providers.

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// The Telehealth Caucus did not provide a timeframe for action, but urged stakeholders to focus on those reforms that “are likely to prompt Congressional action, including ideas that are fiscally responsible and able to generate bipartisan support.” In its comments, AMRPA emphasized that the association has long recognized the benefits of telehealth, remote patient monitoring and other technological innovations, and supports legislative efforts to use these tools appropriately to expand patient access to certain types of providers and services. The Telehealth Caucus did not provide a timeframe for action, but urged stakeholders to focus on those reforms that “are likely to prompt Congressional action, including ideas that are fiscally responsible and able to generate bipartisan support.” AMRPA will be monitoring for new telehealth-related legislation following the RFI and analyzing the effect of telehealth/RPM-related reforms on AMRPA members.

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MedPAC Issues Annual March Report; Recommends 5 Percent Update Reduction for IRFs and Examines PAC Issues as Well as Medicare Advantage

Carolyn C. Zollar, MA, JD, Senior Policy Counsel, AMRPA

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MedPAC recommends 5 percent reduction for IRFs for 2020, citing high IRF margins

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MedPAC’s report to Congress highlights cross-cutting issues in post-acute care

As the cherry blossoms contemplate blooming, the Medicare Payment Advisory Commission (MedPAC) also starts its annual blooming with its first yearly March 2019 Report to the Congress:Medicare Payment Policy. In this report, and pursuant to the law, MedPAC makes payment policy recommendations for nine provider sectors in the fee-for-service (FFS) Medicare program and separately reviews the status of the Medicare Advantage (MA) program. In this year’s report, MedPAC also recommends that Congress replace the four current hospital quality payment programs with a new hospital value incentive program (HVIP) and discusses issues surrounding opioid and non-opioid pain treatment. Finally, the report also includes a short chapter on cross cutting issues in post-acute care (PAC). Summary of Post-Acute Care Recommendations Inpatient Rehabilitation Facilities (IRFs) – MedPAC makes one recommendation specific to 2020: For 2020 the Congress should reduce the calendar year 2019 Medicare base payment rate for inpatient rehabilitation facilities by 5 percent. In addition, it reiterated its March 2016 recommendations that included focused medical record review of IRFs that have unusual patterns of case mix and coding. MedPAC also recommended that the secretary expand the IRF outlier pool to redistribute payment more equitably across cases and providers. Skilled Nursing Facilities (SNFs) - MedPAC includes two recommendations: 1. The Secretary should proceed to revise the skilled nursing facility prospective payment system in fiscal year 2020 and should annually recalibrate the relative weights of the case-mix groups to maintain alignment of payments and costs; and 2. The Congress should eliminate the fiscal year 2020 update to the Medicare base payment rates for skilled nursing facilities. Home Health Agencies (HHAs) – MedPAC recommended: For 2020, the Congress should reduce the calendar year 2019 Medicare base payment rate for home health agencies by 5 percent. Long-Term Care (LTCHs) – MedPAC’s report recommended: For 2020, the Secretary should increase the fiscal year 2019 Medicare base payment rates for long-term care hospitals by 2 percent.

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Inpatient Rehabilitation Facilities In assessing payment adequacy, MedPAC looks at multiple criteria. Yet again, overall the commission found that its indicators for IRF payment adequacy are positive. In 2017 Medicare paid $7.9 billion for IRF care in about 1,180 hospitals and units. About 340,000 beneficiaries had around 380,000 IRF stays. Medicare FFS accounted for 58 percent of IRF discharges. Prior to diving into the payment adequacy analysis, MedPAC updated and reiterated its prior findings regarding patterns of use in IRFs. The Commission notes that by 2008, the number of IRF discharges had fallen by 26 percent, alleging this change was the result of the amendments to the 60 Percent Rule and the list of qualifying conditions which occurred in 2004. Not surprisingly, the average case mix severity and cost per case increased as providers shifted their case load to the conditions which complied with the threshold, and admissions decreased with other cases such as medically complex, arthritis, and lower extremity joint replacements. The report noted that the number of cases with neurological conditions, other than Parkinson’s and neuromuscular disorders, climbed 99 percent between 2008 and 2017. 1. Beneficiary Access to Care MedPAC’s analysis of IRF supply and volume of services and their marginal profit suggested that access remains adequate. Capacity and supply of providers: After declining for several years, the number of IRFs increased in 2014 and continued to grow through 2016, reaching 1,188 facilities nationwide. In 2017, however, the number of IRFs declined slightly, to 1,178 facilities. Over time, the number of hospital-based and nonprofit IRFs has declined, while the number of freestanding and for-profit providers continued to increase. In 2017, the average IRF occupancy rate remained at 65 percent, indicating that capacity is more than adequate to meet demand for IRF services. Volume of services: From 2016 to 2017, the number of Medicare FFS cases declined 2.7 percent, falling to about 380,000 cases after having experienced small annual growth every year since 2010.

3. Providers’ Access to Capital The parent institutions of hospital-based IRFs continue to have good access to capital. The major freestanding IRF chain, which accounted for almost half of freestanding IRFs in 2017 and about a quarter of all Medicare IRF discharges, also has good access to capital. This assessment is reflected in the chain’s continued expansion. MedPAC was not able to determine the ability of other freestanding facilities to raise capital. IRFs’ access to capital in large part depends on their total (all-payer) profitability, and in 2017, total margins for freestanding IRFs were 10.4 percent. Data on all-payer profitability are not available for hospital-based units, but MedPAC examines the all-payer margins of hospitals with IRF units, which, in 2017, had an aggregate all-payer margin of 7.0 percent across all lines of business. 4. Medicare Payments and Providers’ Costs The aggregate Medicare margin for IRFs has grown steadily since 2009 and has been the subject of extensive discussion and deliberation at the commission. In the three-year period between 2015 and 2017, the aggregate IRF Medicare margin remained above 13 percent, and in 2017 stood at 13.8 percent. However, they are widely varied across the sector. Also in 2017, Medicare margins in freestanding IRFs were 25.5 percent, down slightly from their peak in 2015 of 26.7 percent. In 2017, hospitalbased IRF margins were comparatively low at 1.5 percent, but one quarter of hospital-based IRFs had Medicare margins greater than 11 percent, which MedPAC takes as an indicator that many hospitals can manage their IRF units profitably. Lower margins in hospital-based IRFs were driven largely by higher unit costs. In addition, there are notable differences in hospital-based and freestanding IRFs’ mix of cases, which may indicate differences in profitability across case types. Finally, while not definitive, evidence indicates that IRFs’ assessments of patients’ motor and cognitive function are not reliably consistent across providers. To the extent that hospital-based IRFs routinely assess their patients as less disabled than do their freestanding counterparts, their payments—and margins—will be systematically lower. In summary, MedPAC attributes the variation in margins of IRF units to a number of factors. Higher per unit costs is one. Others include less stringent cost controls, a different mix of patients, and assessing patients differently. See T able 10-2 on page 23.

See Tables 10-4 and 10-5 on page 22. 2. Quality of Care The commission tracks three categories of IRF quality indicators: risk-adjusted facility-level change in patients’ functional and cognitive status during the IRF stay, rates of discharge to the community and to skilled nursing facilities, and rates of readmission to an acute care hospital. Most measures were steady or improved between 2012 and 2017. See Table 10-6 on page 23.

Growth in IRFs’ costs historically has been low. From 2009 to 2015, the cumulative growth in cost per discharge was 8.4 percent, well below the 13.5 percent increase in the market basket for IRFs over the period. In 2016, per case cost growth (3.6 percent in aggregate) exceeded payment growth (2.9 percent in aggregate) for the first time since 2008. In 2017, however, per case payments again grew faster than costs (3.4 percent compared with 2.8 percent), resulting in an aggregate IRF margin of 13.8 percent. From 2018 to 2019, MedPAC anticipates costs in IRFs will grow

AMRPA Magazine / May 2019 21

faster than payments, since updates in those years were constrained to 1.0 percent and 1.35 percent, respectively. For 2019, MedPAC projects an aggregate Medicare margin of 11.6 percent. 5. Efficient Providers Pursuant to a requirement in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, MedPAC examined the financial performance of relatively efficient IRFs. It found that relatively efficient IRFs performed better on quality metrics and had costs 18 percent lower than other IRFs. Relatively efficient IRFs were, on average, larger and had higher occupancy rates, contributing to greater economies of scale and lower costs. Freestanding and for-profit facilities were more

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likely to be in the relatively efficient group. MedPAC examined providers that had consistently low costs per discharge and high quality. To be included, the IRF had to be (1) in the best performing third of the distribution of adjusted cost per discharge or of one of the quality measures for three consecutive years (2014-2016) and (2) not in the worst performing third of the distribution of adjusted cost per discharge or either of the quality measures for three consecutive years. Relatively efficient providers also had a higher average case-mix index with more other neurological cases but smaller shares of stroke cases compared to other IRFs. There were many more freestanding and/or for-profit providers in the relatively efficient group.

Cross-cutting Issues in Post-Acute Care The commission examined the PAC space as well and concluded that payments are “unnecessarily high” in the SNF, HHA, and IRF settings. The chapter calls for implementing “substantial changes” to the HHA and SNF payment systems and for continued improvements to setting-specific payment systems until implementation of a unified post-acute care prospective payment system (PAC PPS). The commission previously discussed the challenges to increasing the accuracy of Medicare’s payments and overcoming the shortcomings of the separate FFS payment systems for PAC. MedPAC has worked extensively on PAC payment reform, pushing for closer alignment of costs and payments and more equitable payments across different types of patients.

Despite some actions by the secretary and the congress, MedPAC believes Medicare’s payments remain too high relative to the costs of treating beneficiaries in three of the four settings (SNF, HHA and IRF). However, MedPAC recognizes that the secretary of HHS is making substantial changes to the SNF and HHA prospective payment systems (PPSs) to address overpayment concerns. The commission has two goals in making payment recommendations. The annual update recommendations aim to ensure that aggregate payments are adequate so that beneficiary access is preserved while taxpayers and the long-run sustainability of the program are protected. The recommendations to revise the payment systems aim to align program payments with the costs of treating patients with different care needs. Ideally, such targeting increases the

AMRPA Magazine / May 2019 23

equity of the program’s payments, thereby minimizing the financial incentive for providers to treat some beneficiaries over others. A uniform payment system for all PAC would increase the equity of payments across patients and providers in all settings, but its implementation is on a longer timetable. Until a unified PAC PPS is in place, MedPAC encourages Medicare to continue to improve its setting-specific PAC payment systems, and asserts that FFS Medicare continues to overpay for PAC services. Moreover, MedPAC states that the current HHA and SNF payment systems also create inequities across patients with different care needs and the providers that treat them. Furthermore, the overpayments and misalignments affect the benchmarks for Medicare Advantage plans and alternative payment models. On the quality front, CMS has made progress on defining common outcome measures across PAC providers and establishing value-based purchasing policies for HHAs (on a demonstration basis) and for SNFs. However, the commission is increasingly concerned that trends in some providerreported quality measures raise questions about the accuracy and reliability of this information. The commission is examining the accuracy of the patient assessment-based quality measures. Because patient assessment information affects payments and quality results, it is important that it consistently and accurately

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reflects patients’ levels of function. However, using this information to set payments and measure and reward quality may create incentives for providers to report it in ways that boost payments. Over time, MedPAC has become increasingly concerned and vocal about the validity and utility of provider-reported patient assessment information. MedPAC’s recent analyses of provider-reported measures calculated from patient assessment information have raised concerns that information gathered from these sources may not be accurate. The commission is concerned that when providerreported patient assessment information affects a provider’s payments, providers respond inappropriately to these financial incentives. More information is expected on this analysis in the commission’s June 2019 Report to Congress. Hence, the commission is increasingly wary of the accuracy of the provider-reported patient assessment information. The commission has work underway to assess these data. MedPAC’s initial work on a unified PAC PPS found that payments could be accurate without measures of patient function. The commission is continuing its work on design elements of a unified PAC PPS, including whether function is a necessary component of a case-mix system. Status Report on the Medicare Advantage Program Each year, the commission provides a status report on the Medicare Advantage (MA) program. In 2018, the MA program included about 3,100 plan options offered by 185 organizations, enrolled over 20 million beneficiaries (33

percent of all Medicare beneficiaries), and paid MA plans about $233 billion (not including Part D drug plan payments). To monitor program performance, MedPAC examines MA enrollment trends, plan availability for the coming year, and payments for MA plan enrollees relative to spending for FFS Medicare beneficiaries. It also provided updates on risk adjustment, risk coding practices, and current quality indicators in MA. Enrollment continues to increase in MA programs. Between November 2017 and November 2018, enrollment in plans grew by 8 percent—or 1.6 million enrollees—to 20.5 million enrollees. About 33 percent of all Medicare beneficiaries were enrolled in MA plans in 2018, up from 32 percent in 2017. Among plan types, health maintenance organizations (HMOs) continued to enroll the most beneficiaries (13.1 million), with 21 percent of all Medicare beneficiaries in HMOs in 2018. During this period, enrollment in local preferred provider organizations (PPOs) grew by 16 percent, regional PPO enrollment decreased by 1 percent, and private fee-for-service (PFFS) enrollment decreased by 21 percent. Special needs plan (SNP) enrollment grew by 13 percent, and employer group enrollment grew by 12 percent. Almost all beneficiaries have had access to some type of MA plan since 2006, and HMOs and local PPOs have become more widely available in the past few years. Nearly all Medicare beneficiaries (97 percent) have an HMO or local PPO plan operating in their county of residence. Regional PPOs are available to 74 percent of beneficiaries. 38 percent of beneficiaries have access to PFFS plans. Overall, 99 percent of Medicare beneficiaries have access to a MA plan. Plan payments are dropping below FFS payments. Using the 2019 plan bid data, before adjusting fully for coding intensity, MedPAC estimates that 2019 MA benchmarks (including quality bonuses), bids and payments will average 107 percent, 89 percent, and 100 percent of FFS spending, respectively. Adjusting for uncorrected coding intensity differences would increase the ratio of MA payments to FFS spending by 1 percent to 2 percent; hence, MA payments would average about 101 percent of FFS spending. Lower benchmarks have led to more competitive bids from plans: Bids have dropped from roughly 100 percent of FFS before the Patient Protection and Affordable Care Act of 2010 (PPACA) to 89 percent of FFS in 2019. For 2019, about 76 percent of plans, accounting for 83 percent of projected MA enrollment, have bids below FFS spending. On average, quality bonuses in 2019 will add 4 percent to the average plan’s base benchmark and will add 2.4 percent to plan payments. MedPAC projects the base benchmarks (that is, excluding the quality bonuses) will average 103 percent of FFS spending, and the payments, excluding quality bonuses (and coding differences), will average 98 percent of FFS spending in 2019.

for differences in expected medical expenditures and are based in part on diagnoses that providers code. Most claims in FFS Medicare are paid using procedure codes, which offer little incentive for providers to record more diagnosis codes than necessary to justify ordering a procedure. In contrast, MA plans have had a financial incentive since the current risk adjustment model was introduced to ensure that their providers record all possible diagnoses: Higher enrollee risk scores result in higher payments to the plan. MedPAC’s updated analysis for 2017 shows that higher diagnosis coding intensity resulted in MA risk scores that were 7 percent higher than scores for similar FFS beneficiaries. This estimate is lower than the prior year due to the full implementation of a new risk model and an increase in FFS risk score growth, matching the growth rate of MA risk scores. By law, CMS makes a minimum across-the-board adjustment to MA risk scores to make them more consistent with FFS coding. In 2017, the adjustment reduced MA risk scores by 5.66 percent, leaving MA risk scores and payments about 1 percent to 2 percent higher than they would have been if MA enrollees had been treated in FFS Medicare. The 1 percent to 2 percent estimate is lower than recent years. The adjustment for 2019 will be 5.9 percent. The commission previously recommended that CMS change the way diagnoses are collected for use in risk adjustment and calculate a new coding adjustment that improves equity across plans and eliminates the impact of differences in MA and FFS coding intensity. To summarize, MedPAC finds that many indicators of the performance of the MA program are positive, as evidenced by the growth in enrollment, increased plan offerings, and extra benefits that are at a historically high level. However, it is worth noting that MedPAC has not been able to fully evaluate patient outcomes under MA due to the shortcomings of MA encounter data. Although the payment reforms of PPACA reduced MA payments, the fiscal pressure on MA has improved the efficiency of the MA program. On average across the nation, MA payments are nearly at parity with FFS expenditure levels, consistent with the commission’s support of equity between the two programs. In setting payment policy in the FFS sector, the commission consistently applies a level of fiscal pressure on providers to promote the efficient provision of care while maintaining beneficiary access to good quality care. FFS payment policies of that nature have an effect on MA payments because MA benchmarks are based on FFS expenditure levels, meaning that currently all savings to the program that come from MA must be generated through FFS spending reductions. However, if there were additional fiscal pressure on MA plan benchmarks, plan innovations could contribute more to Medicare savings. In the future, the principle of parity can encompass the concept of achieving an equal level of cost and quality pressure between MA and FFS.

Risk adjustment and coding intensity are increasing. Medicare payments to MA plans are enrollee specific, based on a plan’s payment rate and an enrollee’s risk score. Risk scores account

AMRPA Magazine / May 2019 25

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MedPAC Questions Future Use of ProviderReported Function Data in Post-Acute Care On April 4, the Medicare Payment Advisory Commission (MedPAC) held a public meeting entitled “Evaluating patient functional assessment data reported by post-acute care providers.” The session was a continuation of the Commission’s previously stated concerns regarding the validity of provider-reported patient function data when the data is used in adjusting Medicare payments and quality reporting.

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

Highlight: »»

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MedPAC considers recommendations for CMS to improve the accuracy and validity of provider-reported function data in PAC MedPAC will include a chapter on this topic in its June 2019 Report to Congress

The Commission recognizes that patient functional status is an important dimension of post-acute care (PAC) and is used to adjust payments, gauge provider performance, and establish care plans for patients. The Commission, however, is concerned that providers have responded to the incentives of the setting-specific prospective payment systems (PPSs) and quality reporting programs. Three of the PAC PPSs use function status as a risk adjuster for determining payments. MedPAC has had standing concerns that providers are recording function in ways that do not accurately reflect patient’s care needs, resulting in unnecessary high payments that are not aligned with resource needs and misrepresentative functional outcomes. Last fall, MedPAC discussed examples of what they saw as provider responses to Medicare payment incentives, outlined strategies CMS could pursue to improve the accuracy of the functional assessment data, and discussed a function measure that avoids provider reporting (i.e., patient-reported outcomes). In the April meeting, MedPAC staff built upon their previous work and presented an analysis of 2017 functional assessment data from inpatient rehabilitation hospitals and units (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs). Specifically, the analysis focused on: Comparing same-patient functional statuses of beneficiaries who transitioned between PAC settings: Assessment data at IRF discharge versus at HHA admission Assessment data at IRF discharge versus at SNF admission For IRFs and SNFs, examining the consistency of assessments by comparing the same-patient functional statuses recorded on items used for payment versus on items used for quality reporting. The charts below present MedPAC’s findings. MedPAC examined the consistency of reporting of function items within IRFs and SNFs. They compared the admission assessment results for function items that are used for payment – the setting-specific items – with those used for quality reporting, or the uniform items. MedPAC found that for both IRFs and SNFs, less than half of the admission assessments recorded the same function category in the information

AMRPA Magazine / May 2019 27

Comparison of uniform assessment items recorded at discharge from IRF and at admission to SNF

Comparison of assessment items used for payment with uniform items used for quality reporting

used for quality reporting and the setting-specific items used for payment. The recording favors one direction: The items recorded for quality reporting were more likely to be recorded one function level higher than the information used to establish payments. The results indicate that, even within one setting, the uniform items are reported inconsistently. MedPAC believes this may be explained by the financial incentives of the payment systems to record function as low at admission. They also recognize that the patterns may be due to differences in the setting-specific assessment tools or to provider inexperience with the uniform data items, which are relatively new to PAC settings.

Conclusion At the end of the staffâ&#x20AC;&#x2122;s presentation, they concluded that provider-reported functional assessment data in IRFs, SNFs, and HHAs is currently inconsistent and shows signs of being influenced by payment incentives. They suggested that Medicare not use provider-reported function data to adjust payments. They also suggested CMS improve its monitoring of the accuracy and validity of provider-reported data through the following strategies: Monitor assessments by conducting on-site audits of providers that have aberrant data and assess penalties for poor quality data; Â&#x201E;Â&#x201E; Require PAC medical records to include sufficient documentation to support patient assessments;

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Require hospital discharge assessments (recognizing however that a large share of PAC stays are not preceded by a hospital stay); and Explore ways to gather patient-reported outcomes. Following a brief discussion, the Commissioners supported the staff’s conclusions that Medicare should not use providerreported function data for adjusting payments. However, they also expressed concerns about collecting accurate patientreported outcomes since some PAC patients have cognitive impairments or rely on proxies. MedPAC plans to present its analysis and recommendations in its June 2019 Report to Congress.

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AMRPA: Working Together Access to Medical Rehabilitation AMRPA: Working Together to To Preserve Preserve Access To Medical Rehabilitation Maggie RamirezAMRPA · VP ofMember Membership Services · 347-573-3732 · mramirez@amrpa.org Anna Kruskop, Services Associate, akruskop@amrpa.org, 202-207-1120.

AMRPA Magazine / May 2019 29

Attendees Hear from Policy Makers at 2019 AMRPA Leadership Forum

On March 11-12, more than 100 attendees of AMRPA’s Leadership Forum and Congressional Fly-In heard updates federal officials, stakeholders and staff on the latest developments in medical rehabilitation payment and coverage policies. AMRPA members and other participants were able to engage directly with officials from the White House, the Department of Health and Human Services and the Centers for Medicare and Medicaid Policy (CMS), as well as hear the latest news out of Capitol Hill. Keynote speaker Adam Boehler, Director of the CMS Innovation Center, Senior Advisor to the Secretary of HHS, and CMS Deputy Administrator spoke about the agency’s priorities in fostering health care innovation and moving the needle on value-based care. Prior to joining CMS, he was the founder and CEO of Landmark Health, which provided a home-based care for chronically ill patients. Boehler spoke about his interest in moving away from fee-for-service and looking at models informed by his private sector experience with shifting risk to physicians and helping to keep patients at home. Specific to post-acute care (PAC), he noted the Innovation Center is very interested in a PAC bundle and have been exploring options informed by stakeholder input.

Adam Boehler, Director of the CMS Innovation Center and CMS Deputy Administrator, sits down with Rich Kathrins to discuss the CMS Innovation Center’s priorities.

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Laurence Wilson, Director of the Chronic Care Policy Group and Acting Deputy Director of the Center of Medicare at CMS, provided an overview of his team’s priorities in developing payment policy for PAC. There is interest within CMS to implement payment reform across the PAC silos, as marked by the federal fiscal year (FY) 2019 rules for skilled nursing facilities and home health agencies. Pursuant to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, CMS is authorized to collect two years of standardized PAC patient assessment and quality data and then issue a report to Congress with recommendations for a unified PAC prospective payment system (PAC PPS) based on the data. Wilson noted that while CMS currently anticipates completing this report in 2021, implementing a PAC PPS is a longer term process that will require Congressional action. He also commented that the FY 2019 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) final rule was an important change to advance post-acute care (PAC) reform but CMS recognizes understands providers’ concerns about implementing these changes.

In addition to the other CMS representatives, Brian Elza, Director of the Recovery Audit Contractor (RAC) program at the agency, gave an overview of recent updates to the RAC program. The updates included recent improvements to the program, such as limits on documentation requests, reduced timeframes for medical reviews, and heightened accuracy requirements for contractors. Elza also highlighted the RAC website, which includes approved review topics and additional resources for providers. During a discussion session, Elza heard concerns from hospitals about the qualifications of contractors and other deficiencies in some of the review processes used by RACs. Emily Chen, Ph.D., from the RAND Corporation, provided an update on RAND and CMS’ work in developing standardized patient assessment data elements (SPADEs) for PAC. She presented findings from CMS’ recent national beta test of the IMPACT Act SPADEs. The beta test took place in fourteen markets across the country and involved inpatient rehabilitation hospitals/units, long-term care hospitals, skilled nursing facilities, and home health agencies. Dr. Chen stated that RAND and CMS will be compiling results and findings from the beta test and intend to issue a comprehensive report later this year.

Rich Kathrins, AMRPA Chair of the Board, presents Laurence Wilson with the 2019 AMRPA Chairman’s Award.

Katie Brooks, RN, and Charles Padgett, RN, Nurse Consultants at the CMS Center for Clinical Standards and Quality, discussed the IRF Quality Reporting Program and public reporting of quality data on IRF Compare. The IMPACT Act continues to guide CMS’ work on PAC quality measures, and CMS has been developing a Transfer of Health Information measure for implementation across PAC settings. Ms. Brooks encouraged attendees to attend an IRF QRP Training Event taking place on May 9-10, 2019, in Kansas City, MO. The training would cover changes between the IRF Patient Assessment Instrument (IRF-PAI) version 2.0 and version 3.0 effective October 1, 2019, and provide training on Section GG. CMS plans to overhaul and revamp the legacy QIES, CASPER and QIES Technical Support Office (QTSO) systems to a new iQIES platform. Mr. Padgett reported that CMS has been testing iQIES for long-term care hospitals and anticipates introducing iQIES for inpatient rehabilitation providers later this year.

Emily Chen, PhD, Co-Director of the IMPACT Act Standardized Patient Assessment Data Elements Project, RAND Corporation

Following the presentation from RAND, Jane Lucas, Special Assistant to President Trump for Legislative Affairs, spoke to the audience about the Administration’s health care priorities. Lucas touched on some of the White House’s overarching priorities, such as making prescription drugs more affordable and price transparency for consumers. Lucas also spoke to attendees about concerns over Medicare managed care, and indicated she would raise the issue with appropriate officials.

AMRPA Magazine / May 2019 31

Planning is underway for next year’s Spring Conference! We encourage all AMRPA members, to become involved and serving as advocates for the field and the patients we treat. Stay connected with AMRPA for details to come on the 2020 Spring Conference and Congressional Fly-In. Until then, we hope to see you at our upcoming 2019 events: Regional Meetings Series: Mary Free Bed Rehabilitation Hospital in Grand Rapids, MI (June 7, 2019) Regional Meetings Series: Brooks Rehabilitation Hospital, Jacksonville, FL (June 14, 2019) Fall Education Conference and Expo: Loews Coronado Bay in San Diego, CA (October 14-16, 2019) Jane Lucas, Special Assistant to President Trump, Office of Legislative Affairs at the White House

A panel of post-acute care provider stakeholders give their perspectives on the unifid post-acute care prospective payment system. [From left] Lane Koenig, NALTH Executive Director, William Dombi, President of NAHC, Mike Cheek, Senior VP of Reimbursement at AHCA, Suzanne Kauserud, VP of Carolinas Rehabilitation and AMRPA Board Member.

32 AMRPA Magazine / May 2019

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

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

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

GAO Suggests CMS Revisit Documentation Requirements

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

In March, the Government Accountability Office (GAO) released an analysis of the 2017 improper payment rates for both Medicare and Medicaid. One section of the report in particular compared the improper payment rates between Medicare and Medicaid. The specific services examined included home health, durable medical equipment (DME) and laboratory services. The report relied on figures from the Centers for Medicare and Medicaid Services’ (CMS) Comprehensive Error Rate Testing (CERT) program, which measures the Medicare improper payment rate, and CMS’ Payment Error Rate Measurement (PERM) program, which measures the improper payment rate for Medicaid. GAO took note of a number of large variations in the improper payment rate reported by the CERT and PERM for Medicare and Medicaid, respectively, for the same types of services. For example, for 2017, the CERT reported a DME improper payment rate of approximately 45 percent, while the PERM reported a DME improper payment rate of only 3 percent. GAO said these differences may be at least in part attributable to the fact that Medicare and Medicaid have differing documentation requirements of the same services. In the report, GAO took a look at some of the specific documentation requirements for the services examined. When looking at home health services, GAO noted that Medicare has required documentation of a face-to-face examination by a physician, while many state Medicaid programs had not yet implemented this requirement in 2017. Another example GAO pointed to was the Medicare requirements for documentation from a referring physician for services such as home health, DME and laboratory services. Medicaid, as GAO pointed out, generally does not require such documentation from referring physicians. The chart from GAO highlights some of the differences in improper payment rates, and how insufficient documentation contributed to these error rates. GAO expressed concern that documentation could be sufficient in one program, but lead to a determination of an improper payment in another. This led GAO to call in to question how effective CMS’ documentation requirements are at actually determining whether services are appropriate or not. GAO recommended CMS continue to evaluate its current documentation requirements to ensure they are appropriately tailored to determine whether services are appropriated. CMS has concurred at least in part with this recommendation; the report pointed to CMS’ Patients over Paperwork initiative, which CMS says is working to simplify fee-forservice requirements, including documentation requirements. In addition to documentation requirements, the GAO also pointed out that the use of prior authorization may be leading to noticeably lower improper payment

34 AMRPA Magazine / May 2019

rates for Medicaid when compared to Medicare. The report highlighted that many states require prior authorization for Medicaid coverage of services such as home health and DME. The GAO also said that when prior authorization was tested in the Medicare program, there were significant savings to the Medicare program. This led GAO to reiterate

a recommendation it had made in a report in 2018 that Medicare take steps to expand prior authorization programs for Medicare. The full report can be found at: https://www.gao.gov/ assets/700/697981.pdf

AMRPA Magazine / May 2019 35

Study Examines Trends in Lumbar Fusion Procedures and Costs

Highlights: »»

The volume of elective lumbar fusion increased from 122,679 cases in 2004 to 199,140 in 2015.

»»

Aggregate hospital costs exceeded $10 billion in 2015, and averaged more than $50,000 per admission.

»»

Commercial insurers adopt spinal fusion bundled-payment models.

A recent study published in Surgery describes trends in rates of lumbar fusion procedures and associated costs in the United States. Spinal fusion is appropriate for spinal deformity and instability, but evidence of its effectiveness is limited for primary disc herniation and spinal stenosis without instability. Based on data from the Agency for Healthcare Research and Quality’s (AHRQs) National Inpatient Sample (NIS) from 2004-2015, the number of elective lumbar fusion surgeries has increased by 62.3 percent. The most significant population attributing to these figures are those 65 and older. There is also significant variance in cost for spinal surgery, according to Medicare claims data from January 2012 through March 2015.

// Spinal fusion is appropriate for spinal deformity and instability, but evidence of its effectiveness is limited for primary disc herniation and spinal stenosis without instability.

The volume of elective lumbar fusion increased 62.3 percent (or 32.1 percent per 100,000 U.S. adults), from 122,679 cases (60.4 per 100,000) in 2004 to 199,140 (79.8 per 100,000) in 2015. Increases were greatest among those aged 65 or older, increasing 138.7 percent by volume (73.2 percent by rate), from 98.3 per 100,000 (95 percent confidence interval [CI] 97.2, 99.3) in 2004 to 170.3 (95 percent CI 169.2, 171.5) in 2015. Although the largest increases were for spondylolisthesis (+47,390 operations, 111 percent) and scoliosis (+16,129 operations, 186.6 percent), disc degeneration, herniation and stenosis combined to accounted for 42.3 percent of total elective lumbar fusions in 2015. Aggregate hospital costs increased 177 percent during these 12 years, exceeding $10 billion in 2015, and averaging more than $50,000 per admission. The study found that while the prevalence of spinal pathologies is not known, the rate of elective lumbar fusion surgery in the United States increased most for spondylolisthesis and scoliosis, indications with relatively good evidence of effectiveness. The proportion of fusions coded for indications with less evidence of effectiveness has slightly decreased in the most recent years.

36 AMRPA Magazine / May 2019

Some commercial insurers have implemented bundled payments to coordinate care and manage costs for spinal fusion surgery. Humana announced a new bundled payment model for Medicare Advantage (MA) members who undergo spinal fusion surgery. The model includes four independent physician practices participants. Physicians enrolled in the model and will receive bonuses based on what their costs and quality performance are for lumbar and cervical spinal fusion surgeries. United Healthcare has also offered a similar bundled-payment model, and has shown lower readmission rates and fewer

complication rates as a result of the bundle. This new model is also an extension of a 2016 model that currently has more than 60 medical practices participating. For the study, see Trends in Lumbar Fusion Procedure Rates and Associated Hospital Costs for Degenerative Spinal Diseases in the United States, 2004 to 2015, Spine, March 1, 2019 - Volume 44 - Issue 5 - p 369-376, SURGERY.

AMRPA Magazine / May 2019 37

Environmental Scan Examines Primary Care-Based Efforts to Reduce Readmissions

Highlight: »»

Despite the concerted national efforts resulting from the Hospital Readmissions Reduction Program, an estimated 27 percent of hospital readmissions may still be avoidable.

Each year in the United States more than 35 million patients are discharged from the hospital. The 30-day period immediately after hospital discharge has proven to be a particularly vulnerable time for patients. In the Medicare fee-for-service population, approximately 18 percent of discharged patients will be readmitted to a hospital facility within 30 days, and among the adult Medicaid population the rate is even higher. Readmissions have profound consequences, costing Medicare tens of billions of dollars and leading to delays in clinical recovery. To date, the primary focus has centered on hospital-based interventions to improve care for discharging patients. High-quality controlled studies have demonstrated the benefits of specific protocols hospitals can implement in reducing readmission rates and improving patient outcomes, although not all these programs have been successful. Research from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) indicates high rates of readmissions in the Medicare population and among the adult, non-obstetric Medicaid population. These high rates of readmissions are associated with problems such as prescribing errors and misdiagnoses of conditions in the hospital and ambulatory care settings. Many efforts to reduce readmissions have focused on the hospital setting and staff using evidencebased programs, such as AHRQ’s RED (Re-Engineered Discharge) toolkit, the Care Transitions Intervention, and the Hospital Guide to Reducing Medicaid Readmissions. The evidence-base on how to reduce readmissions for the primary care setting is comparatively lacking. This gap in the literature is becoming more pronounced as primary care is increasingly called to serve as the key integrator across the health care system as part of payment and delivery system reforms. To address this gap, AHRQ funded research to assess what is currently known about reducing readmissions from the primary care perspective. Key Findings The primary care-based literature on care transition programs is less developed than the hospital-based literature. In addition, the diversity of primary care settings makes the implementation and impact of interventions vary, so context is essential to understanding this literature. Multi-component interventions that addressed multiple challenges of patients and providers tended to be more effective than individual interventions. Care transition

38 AMRPA Magazine / May 2019

programs in the context of more general primary care transformation efforts, such as the patient-centered medical home, also tended to be more effective. Much of the research was conducted in large academic health centers, which may not be generalizable to independent primary care practices. The most successful of these programs have been bundled interventions that involve both the pre-discharge and postdischarge periods and offer “bridging” services to improve communication between the inpatient and outpatient settings. Despite the concerted national efforts resulting from the Hospital Readmissions Reduction Program, an estimated 27 percent of hospital readmissions may still be avoidable. It is unclear why care transition efforts to date have not been able to more substantially affect readmission rates. One reason, however, may be that much of the focus of care transition efforts has centered on hospital-based programs. Yet hospital providers may only have a limited ability to affect what occurs once the patient has left the hospital. Hospitals will often schedule a post-discharge follow-up appointment with the patient’s primary care provider, but much less is known about the role of primary care clinics in the care transition process. Primary care providers generally resume care for patients after discharge and providers and staff often have longstanding, trusted relationships with their patients. Increasingly, primary care clinics are also assuming the role of integrators as part of patient-centered medical homes (PCMH), accountable care organizations (ACO), and other team-based approaches to improving care.

It can be difficult to delineate the most effective role of primary care in care transitions as patients require varied services—such as medication reconciliation, transportation assistance—at various times ranging from hospitalization to health management at home. The characteristics of different primary care practices—such as their infrastructure, staffing, and payment model—can greatly affect the extent to which they can support effective care transitions. Primary care may play a small to large role in care transition interventions, and the complexity of these interventions can vary greatly depending on circumstances in their health system environment and relations with other health system members. Conclusion Although there is much potential discussed with regard to the role of primary care in reducing readmissions, the evidence linking the timely follow-up visit on its own to readmission reduction seems mixed. The environment scan found that existing literature differed in their patient populations, operationalization of the follow-up visit, and definition of the readmission outcome. In addition, there were differences in patient medical conditions, education and support. Finally, closer consideration of particular primary care-based care coordination activities is warranted to better understand the mechanisms through which primary care may reduce readmissions. For the study, see Hochman M, Bourgoin A, Saluja S, et al. Environmental Scan of Primary Care-Based Efforts To Reduce Readmissions. (Prepared by John Snow, Inc., under Contract No. HHSP233201500019I/HHSP23337002T) Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.

AMRPA Magazine / May 2019 39

Formerly known as HealthSouth

New name Same commitment

HealthSouth has been committed to a higher level of rehabilitative care for our patients. Under our new name, Encompass Health, we continue to provide the same inpatient rehabilitation services you have come to expect, while also extending our care to include home health and hospice in your area. encompasshealth.com 40 AMRPA Magazine / May 2019

ÂŠ2019:Encompass Health Corporation:1547267

CMS Issues Latest Enrollment and Costs for Dual Eligibles in Medicare and Medicaid

The Medicare-Medicaid Coordination Office (MMCO) within the Centers for Medicare and Medicaid Services (CMS) released a report on enrollment and costs for dual eligibles in Medicare and Medicaid. Dually eligible individuals are Medicare beneficiaries who also receive Medicaid benefits. Dually eligible beneficiaries experience high rates of chronic illness, with many having long-term care needs and social risk factors. 49 percent of dualeligibles receive long-term care services and supports (LTSS), 60 percent have multiple chronic conditions (MCCs) and 41 percent have at least one mental health diagnosis. 17 percent of dually eligible individuals report that they have â&#x20AC;&#x153;poorâ&#x20AC;? health status, compared to 6 percent of other Medicare beneficiaries. Figures 1-5 below describes full versus partial benefits for dual eligibles, Medicare eligibility by age vs. disability, share of Medicaid and Medicare enrollment and costs associated with dually eligible individuals, and the percentage of full-benefit dually eligible individuals enrolled in integrated care. In 2017, there were 12 million individuals concurrently enrolled in Medicare (for the coverage of most preventive, primary and acute health care services and prescription drugs), and Medicaid (for the coverage of LTSS, certain behavioral health services, and Medicare premiums and cost-sharing).

AMRPA Magazine / May 2019 41

For more information, see, People Dually Eligible for Medicare and Medicaid, Medicare-Medicaid Coordination Office. Centers for Medicare and Medicaid Services, March 2019.

42 AMRPA Magazine / May 2019

Supporting Post-Acute Care Transitions in Older Patients with Hip Fracture

Highlights: »»

»»

Medicare paid more than $17 billion per year as a result of hospital readmissions that could have been prevented with proper transitional care. Poorly executed transitions can result in adverse events and compromise patient safety.

A study published in the Journal of the American Medical Directors examined the care transitions of older adults post hip fracture at multiple transitions as they moved through multiple care settings and health care providers. Improving care transitions is of critical importance for older patients, especially those with complex care needs. Transitions of Care (TOC) Care transitions, or Transitions of Care (TOC), are periods of time when an individual moves within or between health care settings, often prompted by a change in functional or health status that requires a different level of care. Older adults with complexities are high users of the health care system and are most at risk for adverse events during transitions. Yet older adults often receive suboptimal care at transitions and are at risk during transitions given the high number of different providers involved and information being incorrectly or insufficiently communicated across settings. Methods The study authors conducted a review of peer-reviewed manuscripts in which data was collected in multiple geographic regions, in acute and sub-acute care wards, rehabilitation programs, home care agencies, long-term care and assisted living facilities, and patients' private homes. The authors also completed 51 interviews with 23 postoperative hip fracture patients aged 65 years and older, 24 interviews with 19 family caregivers, and 96 interviews with 92 health care providers at each transition point for a total of 171 individual interviews. Results Taken together, the framework analysis of the 12 manuscripts identified eight themes related to ToC. Two themes, patient complexity and system constraints, were factors that tended to hinder ToC and were less open to change. The remaining six themes—patient involvement and choice, family caregiver roles, strong relationships, coordination of roles, documentation, and information sharing—have the potential to support and improve ToC. More than half of 2,600 surveyed adults did not receive a written care plan at discharge or receive information on symptoms to monitor and/or whom to contact in case of concern. Poorly executed transitions can result in adverse events and compromise patient safety; for example, in an analysis of medication reconciliation during care transitions, all (100 percent) of the patients reviewed had at least one medication discrepancy. Poor transitions are not only dangerous, they are also expensive and cost Medicare more than $17 billion per year as a result of hospital readmissions that could have been prevented with proper transitional care. For the study, see “A Framework for Supporting Post-acute Care Transitions of Older Patients With Hip Fracture”, Journal of the American Medical Directors Association, March 7, 2019.

AMRPA Magazine / May 2019 43

CMS and CDC Develop Online Infection Prevention and Control Training Course

Highlight: »»

CDC and CMS training aims to reduce health care-associated infections and antibiotic resistance in long-term care settings.

The Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) has launched a free online training course in infection prevention and control for nursing home staff in long-term care (LTC) settings. The courses covers core activities for an infection prevention and control program, with a detailed explanation of recommended practices to prevent pathogen transmission and reduce health care-associated infections (HAIs) and antibiotic resistance in nursing homes. HAIs can result in significant harm or death for residents in LTC facilities and increased health care costs. Infection control is one of the most commonly cited quality deficiencies in nursing homes and the growing concerns over these infection control issues has led to phased-in, revised requirements for participation. The infection prevention and control course is covered in 23 modules and submodules, and includes: Educational course content; Resources (e.g., training tools, checklists, signs, and policy and procedure templates); Modules that can be completed at any time, in any order, and over multiple sessions, depending on the learner’s schedule; and Continuing education credits and a certificate of completion are available for those who complete all modules and pass a post-course exam. The training course and modules are designed to help facilities provide staff with the required specialized infection prevention and control training as it relates to the phased implementation of the Requirements for Participation for Nursing Homes. Course overview and materials are available on the CDC's TRAIN website.

44 AMRPA Magazine / May 2019

Latest Research Findings

Out-of-Hospital, Setting-Based Multidisciplinary Rehabilitation Leads to Improved Mobility in Older Patients After an acute hospitalization, many older adults receive rehabilitation in an out-of-hospital setting (OOHS), however the effect of these interventions on mobility and unplanned hospital readmission is unclear. A recent study published in the Archives of Physical Medicine and Rehabilitation conducted a systematic review and meta-analysis, reviewing literature on multidisciplinary rehabilitation in out-of-hospital settings such as skilled nursing facilities, outpatient clinics or community-based at home) randomized trials studying the effect of multidisciplinary rehabilitation were selected, including those assessing exercise in older patients 65 years and older after discharge from an hospital after an acute illness. A total of 15 studies (1,255 patients) were included in the systematic review and 12 were included in the meta-analysis (seven assessing mobility using the six-minute walk distance [6MWD] test and seven assessing unplanned hospital readmission). Based on the 6MWD, patients receiving rehabilitation walked an average of 23 minutes more than controls (95 percent confidence interval [CI]=: â&#x2C6;&#x2019;1.34 to 48.32; I2: 51 percent). The review found that outof-hospital rehabilitation did not lower the three-month risk of unplanned hospital readmission (risk ratio: 0.93; 95 percent CI: 0.73-1.19; I2: 34 percent). The risk of bias was present, mainly due to the non-blinded outcome assessment in three studies, and seven studies scored this unclearly. The study concluded that OOHS-based multidisciplinary rehabilitation leads to improved mobility in older patients three

months after they are discharged from the hospital following an acute illness and is not associated with a lower risk of unplanned hospital readmission within three months of discharge. For the complete study see, Effects of Postacute Multidisciplinary Rehabilitation Including Exercise in Out-of-Hospital Settings in the Aged: Systematic Review and Meta-analysis, Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 3, March 2019.

AMRPA Magazine / May 2019 45

Study Analyzes the Association of Long-term Exercise Training in Older Adults A recent study published in JAMA Internal Medicine analyzed the association of long-term exercise with the risk of falls, fractures, hospitalizations and death in older adults. Long-term exercise, particularly moderate intensity multicomponent training with balance exercises, performed two to three times per week, appears to be a safe and effective intervention for reducing the risk of being a faller/injurious faller in older populations. However, the benefits of long-term exercise on prevalent adverse events in older populations are not yet established or known.

exercisers (RR, 0.84; 95 percent CI, 0.70-1.00; P = .047). Metaregressions on mortality and falls suggest that two to three times per week would be the optimal exercise frequency to help reduce adverse events.

The authors investigated the association of long-term (≥1 year) exercise interventions with the risk of falls, injurious falls, multiple falls, fractures, hospitalization, and mortality in older adults. The main outcomes and measures were outcomes for the risk of falls, injurious falls, multiple falls, fractures, hospitalization, and mortality.

For the study abstract see Association of Long-term Exercise Training With Risk of Falls, Fractures, Hospitalizations, and Mortality in Older Adults: A Systematic Review and Meta-analysis, JAMA Internal Medicine 2019;179(3):394-405.

Results Forty-six studies (22,709 participants) were included in the review and 40 (21,868 participants) in the meta-analyses (mean [SD] age, 73.1 [7.1] years; 15,054 [66.3 percent] of participants were women). The most frequently used exercise was a multicomponent training (e.g., aerobic plus strength plus balance); mean frequency was three times per week, about 50 minutes per session, at a moderate intensity. Comparator groups were often active controls. Exercise significantly decreased the risk of falls (n = 20 RCTs; 4420 participants; RR, 0.88; 95 percent CI, 0.79-0.98) and injurious falls (9 RTCs; 4481 participants; RR, 0.74; 95 percent CI, 0.620.88), and tended to reduce the risk of fractures (19 RTCs; 8410 participants; RR, 0.84; 95 percent CI, 0.71-1.00; P = .05). Exercise did not significantly diminish the risk of multiple falls (13 RTCs; 3060 participants), hospitalization (12 RTCs; 5639 participants), and mortality (29 RTCs; 11 441 participants). Sensitivity analyses provided similar findings, except the fixed-effect meta-analysis for the risk of fracture, which showed a significant effect favoring

46 AMRPA Magazine / May 2019

The study found that long-term exercise is associated with a reduction in falls, injurious falls, and probably fractures in older adults, including people with cardiometabolic and neurological diseases.

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

Visit our Career Center Here:

careercenter.amrpa.org

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

AMRPA Magazine / May 2019 47

2019 AMRPA Schedule of Events CONFERENCE DATES 2019 Regional Meeting in Grand Rapids, MI Friday, June 7, 2019: Mary Free Bed Rehabilitation Hospital 2019 Regional Meeting in Jacksonville, FL Friday, June 14, 2019: Brooks Rehabilitation Hospital 2019 Fall Educational Conference & Expo in San Diego, California Sunday, October 13, 2019: IRF Boot Camp October 14-16, 2019: Fall Conference & Expo AMRPA WEBINARS Tuesday, May 21, 2019, Noon ET: Maximizing Admission Processes To Drive Bottom-Line Results by Tracey Nixon, MS, CHC AMRPA MEMBERS ONLY CALLS Wednesday, June 19 at 1:00 p.m. ET Wednesday, August 21 at 1:00 p.m. ET Wednesday, October 23 at 1:00 p.m. ET Wednesday, December 18 at 1:00 p.m. ET eRehabData® WEBINARS: AVAILABLE TO eRehabData® SUBSCRIBERS ONLY Tuesday, May 7: Physician Documentation Tuesday, June 4: Managing Outcomes with eRehabData

Please visit www.amrpa.org for registration information.

48 AMRPA Magazine / May 2019

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