AMRPA Magazine | October 2019 by AMRPA

October 2019 â&#x20AC;¢ Vol. 22, No.10

2019

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October 2019 • Vol. 22, No. 10

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 Remy Kerr, MPH AMRPA Health Policy and Research Manager Patricia Sullivan AMRPA Senior Editor Brian McGowan Design and Layout

Table of Contents Letter from the Chair

Legislative Update

Medicare Advantage Flouts Requirements to Comply with Traditional Medicare Coverage Criteria

AMRPA Plays Leading Role in HHS’ Effort to Improve Quality Programs

MedPAC Proposes Value-based Payments for Unified PAC PPS

CMS Proposed to Update Quality Reporting Program for Part B Payments

AMRPA Submits Comments to CMS Request for Information on Reducing Provider Burden

Don’t Miss Out On the First Ever AMRPA Congressional Outreach Boot Camp

AMRPA Political Action Committee (PAC) Seeks to Advance the Cause of IRFs

AMRPA Magazine, Volume 22, Number 10

AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA). AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color. Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Julia Scott, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1110, Email: jscott@amrpa.org. Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content ©2019 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Kellen Company. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 1280, Washington, DC 20045

AMRPA Magazine / October 2019

Letter from the Chair

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

Monitoring Unified PAC PPS During its meeting on September 6, 2019, the Medicare Payment Advisory Commission (MedPAC) presented an overview of its plans to develop a post-acute, value-based payment program. The plan is to combine the value-based program within a unified post-acute prospective payment system (Unified PAC PPS). As reported in AMRPA’s Off the Record (2019, Sept 9), MedPAC would tie a provider’s payment under the Unified PAC PPS to its performance on a variety of metrics. The metrics could include rehospitalizations within the post-acute care stay, discharge to the community, and Medicare spending per beneficiary. Representatives of MedPAC gave a formal presentation (2019, Sept 6). They noted a number of goals for a post-acute, value-based payment program: 1. 2. 3.

Define a set of principles that would tie quality to payment in order to incentivize improvement, A Unified PAC PPS will require a uniform valued-based program across all four PAC settings, and Given that many beneficiaries are treated in different PAC settings, and that MedPAC finds similarities between these settings, providers should be evaluated using uniform measures

MedPAC representatives also noted that the value-based program could be funded by a payment withhold. MedPAC indicated that, a “5% withhold will fund the incentive [valuedbased] program.” They went on to state that, “Medicare margins are high for many PAC providers. A large withhold may be needed to influence behavior (2019, Sept 6).” In large part, I don’t think the health care community is opposed to value-based purchasing programs. The programs would incentivize providers to meet certain metrics in order to improve care and reduce costs. However, I think there are two critical issues at play that are concerning: 1.

While PAC providers have experience with quality reporting programs, these have been pay-for-reporting programs. VBP is pay-for-performance and would be an entirely new dynamic for both providers and policymakers. Furthermore, a uniform VBP spanning the four PAC sectors could have even more dramatic – and as yet unknown – consequences. Any uniform PAC VBP program (whether it comes from MedPAC or from the Center for Medicare and Medicaid Services) should be tested within the post-acute care sector on a small-scale basis before full adoption. In AMRPA’s view, rigorous model testing and vetting is a critical prerequisite for implementation and this principle applies to any and all aspects a Unified PAC PPS, including a PAC VBP program.

AMRPA will continue to closely monitor activities leading to a Unified PAC PPS. In addition, we will track any movement toward a value-based payment program for post-acute care providers to ensure that the aforementioned key principles, are incorporated.

MedPAC Develops Value-Based Payment Program for Unified PAC PPS (2019, Sept). Off the Record. Vol 19 (23). Retrieved from https://amrpa.informz.net/informzdataservice/ onlineversion/pub/bWFpbGluZ0luc3RhbmNlSWQ9ODc5OTg3Nw. Taber, L & Carter, C. (2019, Sept 6). A value-based program for post-acute care providers [Powerpoint slides]. Retrieved from http://medpac.gov/docs/default-source/defaultdocument-library/pac-vip-sept-2019-final.pdf?sfvrsn=0.

AMRPA Magazine / October 2019

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

AMRPA Magazine / October 2019

Legislative Update

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

Highlights: »» »»

»»

»» »»

ongress returned for a short three-week C sprint to a series of important deadlines on September 30. Chief among them is funding the federal government for Fiscal Year (FY) 2020 which begins on October 1, 2019, and various health programs collectively referred to as “health extenders.” The Senate Appropriations Committee worked tirelessly over the recess to ready appropriations bills for markups last month but hit a snag when controversial amendments were proposed during Committee consideration. Surprise billing and prescription drug legislation continue to dominate the policy agenda this fall. CMS finalizes regulations that aim to prevent health care fraud.

AMRPA Magazine / October 2019

Budget Uncertainty for FY 2020 Appropriations Following the enactment of the Bipartisan Budget Act of 2019 last month, the Senate Appropriations Committee worked tirelessly over the recess to ready appropriations bills for markups in September after declining to move forward with markups earlier this year until a budget deal was reached. That process began in earnest with several subcommittee markups during the week of September 9 with plans for a full committee markup on September 12 of the Labor, Health and Human Services and Education (LaborHHS), Defense, State and Foreign Operations, and Energy and Water Appropriations bills. Chair Richard Shelby (R-AL) had indicated the committee is likely to package these four bills together for an initial minibus package, with floor consideration soon to follow. However, Committee Democrats proposed an amendment at the full Appropriations Committee markup that would prohibit the Trump administration from enforcing a rule that prevents federal money from going to organizations that offer abortions or refer patients for abortions. Senate Democrats were accused of using “poison pill” riders to delay consideration of Appropriation bills after both political parties had agreed to not offer controversial partisan policy riders. Movement on the Labor-HHS bill has stalled indefinitely, but the committee intends to move forward with other Appropriations bills. With limited time remaining for negotiations, it is likely that a stopgap Continuing Resolution (CR) will be required to extend government funding past September 30. This would allow more time for the Senate Appropriations Committee to make progress on its work given the late start date and then conference those bills with the versions passed in the House this summer. The House was expected to advance a CR the week of September 16 to fund the government through November 21. In the absence of a breakthrough on any of the deadline-driven items listed above, the CR may carry shortterm extensions of health care programs as well, kicking the can to mid-November on a host of issues. In addition to appropriations, Congress will continue to look for bipartisan paths forward on a host of policy priorities this month, including drug pricing and surprise billing. Fall Action Expected on Drug Pricing and Surprise Billing On July 25, the Senate Finance Committee advanced its drug pricing legislation, the Prescription Drug Pricing Reduction Act, with a majority of Republicans on the panel voting against the package. Looking ahead, additional work will be needed to shore up GOP support for the bill. Senate leaders are holding to their initial plan to combine the Senate Finance package with related legislation reported by the Senate Health, Education, Labor and Pensions (HELP) Committee and the Senate Judiciary Committee. Democrats on the House Ways and Means Committee were scheduled to meet on September 10 and 11 to discuss their next steps on drug pricing and surprise billing, both of which are expected to see committee hearings and possibly mark-ups this month. The

committee is likely to push for aggressive reforms to Medicare Part D, akin to proposals in the Senate Finance bill. Meanwhile, a draft of House Speaker Nancy Pelosi’s (D-CA) drug price negotiation plan was leaked in early September. The Speaker’s legislation makes changes to Medicare Parts B and D, including changing beneficiary cost-sharing responsibility for Part D drugs, establishing a new manufacturer discount program in the initial and catastrophic Part D coverage periods, and requiring inflationary rebates for all Parts B and D drugs. Additionally, the bill establishes a methodology for identifying 250 brand name drugs without price competition plus insulin that would be subject to negotiation. The Secretary of the Department of Health and Human Services (HHS) would negotiate with drug manufacturers for a “maximum fair price,” which is defined as an upper limit of no more than 1.2 times the volume-weighted average of the price of six countries (Australia, Canada, France, Germany, Japan and the UK). Manufacturers that do not participate in negotiations would be subject to a penalty that is 75% of the gross sales of the drug in question from the previous year. The savings generated from the plan would be redirected to fund biomedical research and potentially new Medicare benefits or reduced cost sharing. Following the August recess, the House Education and Labor Committee was planning a mark-up of the “No Surprises Act," which was reported by the House Energy and Commerce Committee in July. The bill utilizes a benchmark payment approach based on the median in-network rate, along with a backstop arbitration process added during markup. The Ways and Means Committee is expected to release its own surprise billing legislation before the end of the month, though details on the payment methodology and other aspects have yet to be released. In the Senate, additional changes are expected to the HELP Committee’s “Lower Health Care Costs Act,” which currently utilizes a benchmark payment approach, in order to secure support from a majority of Senate Republicans. House Committee Highlights Prior Authorization Bill On September 11, the House Committee on Small Business held a hearing titled, “Utilization Management: Barriers to Care and Burdens on Small Medical Practice.” Committee members heard from four physicians representing different medical specialties on how utilization management programs such as prior authorization and step therapy, force doctors to spend their time working with insurance companies and pharmacy benefit managers instead of treating patients. Dr. John Cullen, representing the American Academy of Family Physicians, explained, “The prior authorization process is out of control. It is increasing and rather than a tool for preventing unnecessary or expensive care, prior authorization negatively impact my patients’ health.” Oncologist Dr. Paul

Harai noted his concern that health insurance reviewers are often not familiar with the specialty they are reviewing, and therefore inexperienced with the patient’s condition or the prescribed therapy or treatment plan. Committee Members highlighted the “Improving Seniors’ Timely Access to Care Act of 2019” (H.R. 3107), legislation endorsed by AMRPA’s Board, would streamline and loosens prior authorization requirements for “medically necessary” procedures. More than 370 groups have signed onto a letter that supports passage of the legislation introduced by Reps. Suzane DelBene (D-WA) and Roger Marshall (R-KS). CMS Issues Program Integrity Final Rule On September 5, the Centers for Medicare and Medicaid Services (CMS) released a final rule with comment period aimed at preventing health care fraud within Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). The final rule requires health care providers to disclose to CMS if they are affiliated with entities currently, previously or indirectly that have uncollected debt or have been excluded from federal health care programs for fraud, waste and abuse. Beginning November 4, the rule allows CMS to revoke or deny Medicare enrollment to a “bad actor” provider or entity. Providers and suppliers can be blocked from reentering the Medicare program for up to 10 years. CMS estimates the new policy will save the federal government almost $50 billion over 10 years. *** As we get closer to the end of the year (and closer to election season), Congress will have difficult policy decisions to make and the political environment becomes even more heightened. Please utilize the October Congressional Recess to reach out to your members of Congress to alert and educate them on the negative impact of prior authorization for inpatient rehabilitation services and urge Congress to reform the prior authorization program in Medicare. Members of Congress need to be educated about the adverse impact of the use of prior authorization in the Medicare Advantage (MA) program, and the care delays and patient access issues that such policy presents certain types of providers, including inpatient rehabilitation hospitals and units. We would be pleased to discuss the topics and assist you with materials for any meeting(s) you set up. We would be happy to provide you with any additional information and assistance you may need in reaching out to your members of Congress. Please be in touch if you need any assistance! In this still-new Congress, we greatly appreciate your time and willingness to help AMRPA build relationships and educate members of Congress about key issues of concern to the field.

AMRPA Magazine / October 2019

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2019 AMRPA Schedule of Events CONFERENCE DATES 2019 Fall Educational Conference & Expo in San Diego Sunday, October 13, 2019: IRF Boot Camp Sunday, October 13, 2019: Congressional Outreach Boot Camp October 14-16, 2019: Fall Conference & Expo REGISTRATION NOW OPEN! AMRPA WEBINARS Wednesday, November 6 from 12:00 p.m. - 1:00 p.m. ET Arrangements with Physicians and Other Risks: What You Don’t Know Can Hurt You Presented by Christina A. Hughes, JD, MPH AMRPA MEMBERS ONLY CALLS 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 Visit eRehabData.com for more Information.

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AMRPA Magazine / October 2019

Medicare Advantage Flouts Requirements to Comply with Traditional Medicare Coverage Criteria

Peter W. Thomas, JD, Principal, Powers Pyles Sutter & Verville, PC

As most providers are aware, under the Medicare Advantage (MA) program (also known as Medicare Part C), the federal government contracts with private health insurance companies (called Medicare Advantage Organizations or MAOs) for the administration of Medicare beneficiaries’ benefits under a capitated payment system.1 The MA program covered 21 million people in 2018 – around one-third of all Medicare beneficiaries.2 A key concern about the capitated payment model used in the MA program is the potential incentive for MAOs to inappropriately deny services and payment in an attempt to manage utilization of benefits (i.e., limit overutilization and/or increase profits) despite requirements for the benefits covered to be equivalent to those for beneficiaries under traditional Medicare. A recent Office of the Inspector General (OIG) report found that inappropriate use of prior authorization or payment denials may contribute to physical or financial harm to beneficiaries and providers, as well as the misuse of Medicare dollars that the Centers for Medicare and Medicare Services (CMS) has paid to MAOs for beneficiary health care.3 Aside from the concerns raised by prior authorization (as discussed in previous articles), real concern exists about the coverage standards being used by the MAOs in determining whether to cover items and services, particularly admission to inpatient rehabilitation hospitals and units.

Christina Hughes, JD, MPH, Counsel, Powers Pyles Sutter & Verville, PC

MA Coverage Rules Under Section 1852 of the Social Security Act, MA plans must offer all “benefits under the original Medicare fee-for-service program.”4 The law defines these “basic benefits” as all “items and services” covered under Medicare Parts A and B, except for hospice care or coverage for kidney transplants.5 The Medicare regulations further emphasize that MA plans must provide all Medicare-covered services. Under 42 C.F.R. § 422.101(a), MA plans are required to “[p]rovide coverage of, by furnishing, arranging for, or making payment for, all services that are covered by Part A and Part B of Medicare.” In addition, MA plans are required to comply with all Medicare national and local coverage determinations and all Medicare manuals and instructions, unless superseded by regulation.6 The Medicare manuals also require that MA plans offer all Medicare

42 U.S.C. §§ 1395w-21 – 1395w-28.

.S. Dep’t of Health & Human Servs., Office of Inspector General (“OIG”), OEI-09-16-00410, Medicare Advantage Appeal Outcomes and Audit Findings U Raise Concerns About Service and Payment Denials (Sept. 2018).

Id.

42 U.S.C. § 1395w-22(a)(1)(A).

42 U.S.C. § 1395ww-22(a)(1)(B)(i).

42 C.F.R. § 422.101(b).

10 AMRPA Magazine / October 2019

covered services. The Medicare Managed Care Manual (MMCM) states that “an MA plan must provide enrollees in that plan with all Part A and Part B original Medicare services.”7 The MMCM further states that “[a]ll MA plans must offer. . . all medically necessary Medicare Part A and Part B services, including Part B prescription drugs, as basic benefits.”8

particularly when they are ill or injured awaiting discharge to the next setting of care they may require. In addition, once hospital discharge planners know that a specific MA plan routinely denies or delays IRF referrals for admission, they often stop even trying to refer patients to an IRF. In this manner, the MA plans win at the patient’s expense.

MA Plans are Routinely Not Following Medicare FFS Rules Despite the requirement that MA plans must provide the same services that are covered under original Medicare, as explicitly outlined above, there have been indications that some MA plans are declining to do so. Most egregiously, in a non-rehabilitation context, at least one MA plan issued an updated policy in January 2019 that stated that the MA plan will no longer follow the Two Midnight Rule, which applies to inpatient hospital admissions, due to the erroneous statement that CMS has suspended the rule.9 The MA plan’s incorrect belief that CMS had suspended the Two Midnight Rule may have been the result of guidance that CMS issued in early January 2019 about the application of the rule to total knee arthroplasty that incorrectly stated that the rule did not apply to Critical Access Hospitals—CMS has since withdrawn this guidance and issued a corrected guidance document.10

In response to the MA Call Letter (a letter that signals to MA plans what CMS wants to see if the annual MA plan requests to participate in the MA program) issued by CMS in February of each year, commenters have repeatedly asked CMS to instruct MA plans to cease using Milliman and InterQual guidelines to determine IRF coverage and, instead, rely on the same coverage requirements applicable to Medicare beneficiaries under the traditional Medicare program. However, CMS has declined to do so. The use of these non-Medicare guidelines appears to be inconsistent with the requirements that MA plans provide the same benefits as original Medicare and comply with the Medicare manuals, as discussed above. However, it is often difficult to determine exactly how impactful the use of the non-Medicare criteria is to a claim denial decision. This is because the MAOs frequently omit the full rationale for a denial of care when the Milliman or InterQual guidelines are applied, citing the proprietary nature of the guidelines themselves.

While the information in this example was blatantly erroneous, there are also significant barriers under the MA program for patients trying to access inpatient rehabilitation hospitals and units (commonly known as IRFs) in line with Medicare requirements. Based on reports from IRF providers, many MA plans do not use Medicare IRF coverage criteria when determining coverage for IRF care. Instead, these plans apply private, proprietary decision support tools, including Milliman and InterQual guidelines, to make their decisions as to which rehabilitation patients to admit to IRFs verses skilled nursing facilities or home health agencies. In addition to being outside of the coverage criteria established by Medicare Part A, these guidelines often contradict well-established best practices in medicine, such as the American Heart Association and American Stroke Association’s (AHA/ASA) guidelines for stroke recovery. AHA/ASA “strongly recommends that stroke patients be treated at an inpatient rehabilitation facility rather than a skilled nursing facility.” The use of non-Medicare coverage criteria tends to divert Medicare beneficiaries to less intensive rehabilitation settings than they are entitled to under the Medicare program, potentially risking the health and functional potential of beneficiaries. In fact, the Medicare Payment Advisory Commission (MedPAC) found that 2015 MA admissions to inpatient rehabilitation hospitals were one-third of admissions to this same setting under Medicare feefor-service.11 The problem is particularly pernicious because most MA beneficiaries are not savvy to their post-acute care options,

Conclusion The OIG report referenced above also found that audits by CMS have uncovered widespread and persistent MAO performance problems related to denials of care and payment. The OIG recommended that CMS should enhance its oversight of MAO contracts, including those with extremely high overturn rates and/ or low appeal rates, and take corrective action as appropriate; CMS should address persistent problems related to inappropriate denials and insufficient denial letters in the MA program; and CMS should provide beneficiaries with clear, easily accessible information about serious violations by MAOs. CMS agreed with these recommendations, but did not provide additional detail about how or when CMS plans to implement these recommendations. In light of these serious concerns and the opaqueness of the MAOs’ claim determination process, it is critically important that inpatient rehabilitation hospitals and units carefully monitor their interactions with MAOs and push back whenever feasible on the use of criteria that differ from the coverage standards applicable under Medicare Part A.

MMCM, CMS Pub. 100-16, ch. 4, § 10.2.

Id. at ch. 4, § 10.3.

he relevant provision of Security Health Plan’s provider manual is available here: https://www.securityhealth.org/providers/provider-manual/medicareT advantage/care-management/two-midnight-rule.

he corrected guidance is available here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downT loads/SE19002.pdf. The previous version of the guidance is available here: https://kslawemail.com/128/4816/uploads/mln-matters-se19002-tka-status.pdf.

MedPAC, Report to the Congress: Medicare Payment Policy, p. 298 (Mar. 2017).

AMRPA Magazine / October 2019 11

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12 AMRPA Magazine / October 2019

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Stay informed! Order your PAC report today. AMRPA Members Receive Reports at Discounted Rates. Visit www.amrpa.org/PAC-Market-Analysis-Reports for more information, or contact Julia Scott, AMRPA Member Services Coordinator, jscott@amrpa.org.

AMRPA Magazine / October 2019 13

AMRPA Plays Leading Role in HHS’ Effort to Improve Quality Programs

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

In June 2019, the Trump administration issued an executive order that called on the Department of Health and Human Services (HHS) and other departments to “make meaningful price and quality information more broadly available to more Americans” in an effort to “protect patients and increase competition, innovation and value in the healthcare system.” Specifically with respect to quality programs, the executive order called for HHS, in conjunction with the Department of Defense (DoD) and Department of Veteran Affairs (VA), to develop a “Health Quality Roadmap” (“Roadmap”) aimed at aligning and improving quality data and quality measures across Medicare, Medicaid, the health insurance marketplaces, and other federal health programs. The Roadmap is required to include a clear strategy for: establishing, adopting and publishing common quality measurements; aligning inpatient and outpatient measures; and eliminating low-value or counterproductive measures. The executive order outlines an aggressive timeframe for development, requiring the Roadmap to be submitted within 180 days of the order’s issuance (late December 2019). AMRPA joined other provider stakeholders in closely tracking HHS’ response to this report, given the association’s longstanding advocacy for improvements within the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP), as well as with respect to other broader quality measuring and reporting issues. To that end, HHS announced formation of a “Quality Summit” in July 2019 to help develop the Quality Roadmap and provide other quality improvement-related recommendations to HHS throughout a one-year engagement. HHS called for stakeholders to nominate health care leaders with significant experience with HHS’ quality programs, and AMRPA nominated Dr. Sally Brooks, chief medical officer of Kindred Hospital Rehabilitation Services, to serve on the distinguished panel. AMRPA subsequently applauded HHS’ August 2019 announcement that Dr. Brooks was selected from among 300+ nominees, as Dr. Brooks’ participation on the Summit represents a key opportunity for the rehabilitation hospital industry to offer its perspective as HHS considers large-scale changes to its current quality measures, reporting rules and other related issues. Some of the other 18 participants include health system CEOs, leaders from quality-focused think tanks and nonprofit organizations, chief quality and chief medical officers from hospital systems, and a current member of the Medicare Payment Advisory Commission (MedPAC), among other distinguished panelists. According to HHS, the Quality Summit panelists will discuss and analyze several overarching quality issues as part of the development of the Roadmap, including:

14 AMRPA Magazine / October 2019

Ways to modernize HHS’ quality programs with the goal of creating a “patient-centered approach that increases competition, quality and access to care;” Approaches to identifying burdensome regulations in current HHS quality programs; and Developing or identifying mechanisms needed to improve providers’ abilities to deliver high-quality care to their patients. The Quality Summit is scheduled to meet on a monthly basis in September, October and November, leading up to the submission of the Quality Roadmap in December (subsequent meetings are anticipated to continue following the Roadmap’s submission). The first meeting in September focused on how an ideal future health care Quality Measurement Enterprise (QME) should be structured, with participants asked to identify ways that quality programs can work for providers and patients and what rules/structures are hindering patient-centered care and innovation.

Modernizing the IRF QRP via changes to the completion threshold, reporting burdens related to certain measures, and ensuring that the publicly reported QRP data are meaningful to consumers; Ensuring that the standardized patient data assessment elements (SPADEs) that are implemented pursuant to the IMPACT Act prioritize clinical utility and patient-facing value; and Implementing measures in a way such that they are appropriately risk-adjusted and promote the care of all patients who need services, including inpatient rehabilitation. According to HHS’ Quality Summit materials, the Roadmap will be submitted by the HHS, DoD and the VA Interagency Steering Committee to the president on December 21, 2019, and the departments will oversee its subsequent implementation. AMRPA will continue to provide members with updates on the discussions and potential policy changes that spring from this exciting initiative.

AMRPA has engaged extensively with HHS with respect to quality issues, and will be closely watching whether and how the Summit addresses some of the association’s key issues – such as:

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

Elizabeth Katsion, AMRPA Member Services Associate, ekatsion@amrpa.org, 202-207-1102.

AMRPA Magazine / October 2019 15

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18 AMRPA Magazine / October 2019

MedPAC Proposes Value-based Payments for Unified PAC PPS

On September 6, the Medicare Payment Advisory Commission (MedPAC) held a public meeting session titled, “A value incentive program for post-acute care providers,” to discuss the development of a value-based purchasing program for the unified postacute care (PAC) prospective payment system (PPS). The commission has previously recommended that the unified PAC PPS link payments to quality and value, and it has developed a set of principles for value-based design through its work on the Hospital Value-based Purchasing Program.

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

Highlights: »»

»» »»

edPAC begins to develop a valueM based payment program for the unified PAC PPS to tie payments to quality and value The PAC Value Incentive Program (PACVIP) would score each of the four PAC settings separately initially MedPAC suggests a 5% withhold from provider payments to fund the PAC-VIP

At the September meeting, MedPAC staff presented a PAC value incentive program (VIP) that would tie a portion of a provider’s payments to quality and value using a common set of population-based measures. Background In 2016, MedPAC recommended that a value-based purchasing program be implemented with the unified PAC PPS to incentivize improvement in inpatient rehabilitation hospitals and units (IRFs), skilled nursing facilities (SNFs), home health agencies (HHAs) and longterm care hospitals (LTCHs). Given the overlap of the types of patients receiving PAC in different settings, MedPAC believes a single PAC-VIP would allow comparisons of patient outcomes and quality of care across all four settings. Currently, there are two Medicare VBP programs in PAC, the HHA VBP and the SNF VBP. The HHA VBP is composed of 20 measures and has a progressive withhold of up to 8%; the SNF VBP includes one readmissions measure and uses a 2% withhold. In MedPAC’s view however, these programs currently do not meet the commission’s principles for value-based design as neither program uses population-based outcomes measures that assess quality, patient experience, and resource use, nor do they consider social risk factors in translating performance into payment. Proposed PAC-VIP Program MedPAC staff presented the design elements of a PAC-VIP and proposed using three uniform, claims-based measures: All-condition rehospitalizations within the PAC stay: Discharge to the community: Medicare spending per beneficiary (MSPB) Although the Centers for Medicare and Medicaid Services (CMS) currently has such measures implemented across the various PAC quality reporting programs, MedPAC does not consider CMS’ measures to be uniformly standardized across settings and has therefore developed their own measures for the PAC-VIP.

AMRPA Magazine / October 2019 19

MedPAC has conducted preliminary modeling and found “considerable” variation in performance rates across settings. The staff attribute these variations to inherent differences across settings, such as provider competencies (as defined by Medicare Conditions of Participation), shares of dual-eligible beneficiaries treated, and differences in average lengths of stay. Given the variations, staff suggest that the PAC-VIP be scored within each setting (i.e., IRFs with IRFs) initially, with a progression to crosssetting comparisons when a unified PAC PPS is implemented and uniform standards could be applied across settings. MedPAC also proposes to account for social risk factors by comparing providers against peers with similar shares of dual-eligible beneficiaries. To fund the PAC-VIP, MedPAC staff propose a 5% payment withhold to start that would increase over time. The staff commented that Medicare margins have been high in the PAC sector and a “large withhold may be needed to influence” provider behavior. Performance would be scored using prospectively set targets in setting-specific peer groups (i.e., IRFs would be compared with other IRFs that have a similar share of dual-eligible beneficiaries). Each peer group would have a pool of dollars that is redistributed within the group, and providers would receive a bonus or penalty based on their performance relative to peers. Because many PAC providers have relatively low volumes, MedPAC intends to use claims data pooled over three years to help improve measure reliability for low-volume providers and to include as many providers as possible in the program. Commissioner Discussion and Next Steps In concluding their presentation, the staff sought feedback from the commissioners regarding the proposed measures, scoring methodology, and size of the withhold percentage. In the discussion, the commissioners supported the direction of the work thus far and provided several recommendations for the continued development of the PAC-VIP. These include: adding functional status and patient experience measures;

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// Over the coming months, MedPAC staff will incorporate the commissioners’ feedback to develop an outcomesbased PAC-VIP that is consistent with the commission’s principles for quality and value. comparing patient outcomes by clinical condition versus by setting of care; incorporating additional indicators to study the impact of social risk factors, beyond a beneficiary’s dual-eligible status; and evaluating the robustness of claims data to ensure that comorbidities and other pertinent clinical characteristics are accounted for in a unified PAC model. Over the coming months, MedPAC staff will incorporate the commissioners’ feedback to develop an outcomes-based PAC-VIP that is consistent with the commission’s principles for quality and value. The staff will model the PAC-VIP and present the results in the spring. Presentation slides associated with this meeting and a transcript are available at www.medpac.gov.

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AMRPA Magazine / October 2019 21

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CMS Proposed to Update Quality Reporting Program for Part B Payments

Jonathan M. Gold, JD, AMRPA Director of Government Relations & Regulatory Counsel

Highlights:

»» »»

IPS Payment Adjustments Proposed to M Rise to 9% for CY 2020 Claims CMS Seeks Information on Major Rework of MIPS Reporting

On August 14, the Centers for Medicare and Medicaid Services (CMS) published the Physician Fee Schedule and Quality Payment Program (QPP) proposed rule for calendar year (CY) 2020 in the Federal Register. The QPP adjusts Part B payments to providers based on either performance in the Merit-based Incentive Payment System (MIPS), or participation in certain alternative payment models (APMs). The QPP was created by the Medicare and CHIP Reauthorization Act of 2015 (MACRA), which repealed the sustainable growth rate (SGR) formula that was previously used to update physician payments under Medicare Part B. The QPP also replaces several previous programs for physicians, including the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program, often referred to as “Meaningful Use.” The QPP, currently in its third year, is composed of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). Under the QPP, certain clinician types who meet certain eligibility thresholds are considered MIPSeligible clinicians (MECs). A MEC will receive a score based on their performance in MIPS, which will then be used to adjust their PFS payments. A MEC may be excluded from MIPS if they participate in an AAPM. AAPMs are essentially an alternative track to MIPS, and allow clinicians who are otherwise MECs to be exempt from MIPS and receive a 5% positive payment adjustment for successful participation in an AAPM for a payment year. The remainder of this article highlights key features and proposed changes to MIPS. MIPS Overview Under MIPS, MECs are evaluated across four performance categories: Quality, Cost (resource use), Improvement Activities and Promoting interoperability (PI), which was previously referred to as Advancing Care Information (ACI), and is a replacement of the EHR Incentive Program. Clinicians receive a total score between 0-100, which will result in a positive, neutral or negative payment adjustment. Each of the four categories is scored separately, weighted, converted to a numerical score, and then added to the MEC’s final score. Clinicians can also report as groups, either as an actual group practice or as a virtual group that comes together for purposes of reporting. Most of the same reporting requirements generally also apply to groups. For purposes of this article, both individual and groups of MECs will be referred to as “MECs.” The MIPS payment adjustment began at a possible adjustment of up to 4% of total payments for the first year (2017). It increased to 5% for 2018, and will increase to 7% in

AMRPA Magazine / October 2019 23

2019 until leveling off at plus-or-minus 9% in 2020 and thereafter. Originally, the MIPS payment adjustment was to apply to billed services and separately billed items, such as Part B drugs. However, the Bipartisan Budget Act of 2018 (BBA 2018) amended MACRA to make the payment adjustment applicable only to professional services, and not separately billed items, such as drugs. MIPS generally uses a two-year delayed payment system, so that services and scores achieved in CY 2020 (referred to as performance year 2020) will be used to adjust payments for 2022 (referred to as payment year 2022). For purposes of this article, references to a year refer to the performance year. The currently eligible MIPS clinician types are physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine and optometry), chiropractors, physician assistants, nurse practitioners, certified registered nurse anesthetists, physical therapists, occupational therapists, psychologists, speech-language pathologists, audiologists and registered dietitians or nutrition professionals. If these clinician types are not otherwise excluded due to low-volume of services or other exceptions such as participation in an AAPM, they are required to participate in MIPS. It should be noted that estimates show that the vast majority of therapists, including physical and occupational therapists, do not meet the low-volume threshold and are excluded. Inclusion of New Clinician Types Last year, CMS added a number of new clinician types to MIPS for the first time, including: therapists, psychologists, speech-language pathologists, and dieticians. However, because of a technicality in how MIPS scores are calculated and attributed, many therapists will not have an opportunity to participate in MIPS. This is because CMS uses the unique combination of the Tax Identification Number (TIN) and rendering National Provider Identifier (NPI) of a specific, individual provider. Therefore, CMS states, if the claims submitted by a hospital or facility do not include the rendering NPI of the specific clinician performing the service, the claims will not be attributable for MIPS purposes. In addition, therapists providing services on an inpatient basis do not bill under Part B, and therefore are not eligible clinicians. AMRPA has recommended that CMS find a way to include facility-based outpatient therapy services in MIPS, but CMS has thus far declined to do so. Request for Information on MIPS Value Pathways (MVPs) In this year’s proposed rule, CMS is proposing a major overhaul of MIPS for future years. The agency states it has received considerable feedback that MIPS is excessively burdensome and fragmented, with providers reporting random elements across different categories. CMS says it is seeking ways to reduce reporting burden and more carefully tailor reporting requirements to certain types of providers. CMS is proposing to begin implementing what it is calling MIPS Value Pathways (MVPs), which would be an option to participate by reporting integrated measures that span across different categories of MIPS reporting. These pathways would be organized around certain clinician specialty or health conditions. Generally, CMS says if a clinician chooses to participate in an MVP, they would

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have fewer total measures to report than if the clinician were to use the current framework of meeting each category’s reporting requirement individually. CMS has laid out a number of overarching principles it envisions for MVPs, and asks providers to weigh in on how to best implement these principles. The principles CMS proposes are: MVPs should consist of limited sets of measures and activities that are meaningful to clinicians, which will reduce or eliminate clinician burden related to selection of measures and activities, simplify scoring, and lead to sufficient comparative data. MVPs should include measures and activities that would result in providing comparative performance data that is valuable to patients and caregivers in evaluating clinician performance and making choices about their care. MVPs should include measures that encourage performance improvements in high priority areas. MVPs should reduce barriers to APM participation by including measures that are part of APMs where feasible, and by linking cost and quality measurement. CMS proposes that it would implement MVPs beginning in 2021, so there will be at least one more performance year (2020) of the current MIPS program. In addition, CMS proposes that beginning in 2020, organizations that nominate quality measures must link those nominated measures to existing and related cost measures, which is not currently required. Further, CMS proposes that each MVP have a uniform set of promoting interoperability (PI) measures consistent with current PI standards. Therefore, the biggest changes would be integration of the quality and the cost and improvement activities categories. CMS seeks feedback on all aspects of transitioning to MVPs, including how it would impact certain specialties or practices differently, how to best determine appropriate measures for use in MVPs, and many other aspects of the implementation of this proposal. Low-volume Threshold Exclusion CMS sets a low-volume threshold to exclude clinicians from MIPS that do not meet a certain volume of services in a performance year. There are currently three thresholds, and if a clinician falls below any three of those thresholds, they are not required to participate in MIPS. The three low-volume exclusion thresholds are: $90,000 or less in professional services in a year; 200 or fewer Part-B Medicare patients in a year; or 200 or fewer covered professional services in a year; however, CMS also permits a clinician who exceeds at least one of the low-volume thresholds to opt-in to MIPS. Only those clinicians or groups that exceed all three of the thresholds will be required to participate in MIPS. CMS is not proposing any changes to the low-volume threshold for CY 2020.

The Four Performance Categories As previously discussed, MECs are evaluated and scored under four categories: quality, promoting interoperability (PI), cost and improvement activities (IA). Under all categories except cost, MECs must submit measures to CMS for scoring. MECs earn a score within each category, which is weighted and applied towards a final score of between 0-100. The final score then is applied to a percentile that determines the payment adjustment. Overall, CMS proposes slight adjustments in the weighting of two of the four categories. CMS proposes to lower the weight of the quality category from 45% to 40%. It also proposes to raise the cost weight from 15% to 20%. CMS proposes to keep the PI category at 25% and the improvement activities category at 15%. It should be noted that certain provider types, including therapists, can have certain categories reweighted to zero. Therapists automatically have the PI category reweighted to zero unless they voluntarily submit PI measures. Further, the cost category for most clinicians is determined via attribution of certain evaluation management codes billed for a patient by that clinician. Therapists do not bill these codes, which are primarily physician codes; therefore, most therapists and other non-physicians will have both PI and cost categories reweighted to zero. This results in quality making up 85% of the score and improvement activities making up the remaining 15% of the score. Quality Performance Category The quality category requires MECs to submit quality measures to CMS, which are scored against a benchmark developed for that measure. There is a total possible score of 60 for quality measures, which is then converted to a different number to be applied to the final, total MIPS score. There are several ways MECs can report quality measures. These include Electronic Clinical Quality Measures (eCQMs), MIPS CQMs (formerly "Registry Measures"), Qualified Clinical Data Registry (QCDR) Measures, and Medicare Part B claims measures. For each of the types of reporting there is a completion threshold that the provider must attain. CMS is proposing to raise the completion threshold for all types of reporting from 60% data completion to 70% data completion. MECs must report at least six quality measures from CMS’ list of approved quality measures, including one measure that is designated as an outcome measure. Alternatively, CMS has developed specialty sets, and a MEC can choose to report on the entire specialty set, even if the set has less than six measures, and satisfy the reporting requirements. Except for those clinicians considered facility-based, as discussed below, current quality measures can be explored on the CMS website at qpp.cms.gov/ mips/quality-measures. CMS is proposing to remove or add a number of measures to the general list of measures, and these changes can be found in Table A in Appendix 1 one of the proposed rule. CMS is also proposing removing or adding a number of measures from specialty sets, which can be found in Table B in Appendix 1 of the proposed rule. Changes to the Physical Medicine Specialty set is found in table B.15 in Appendix 1 of the proposed rule. CMS is proposing to remove the following measures from the Physical Medicine specialty set:

Pain Assessment and Follow Up (NQF #0420) Osteoarthritis (OA) Function and Pain Assessment Similar to other pain measures it is removing from reporting programs, CMS is proposing to remove NQF #0420 from the MIPS program due to the controversy surrounding the potential correlation between assessment of pain and increase in prescriptions for opioid medications. CMS says it is proposing to remove the osteoarthritis assessment measure because it is duplicative of other measures. CMS is also proposing to remove or add a number of new measures from the Physical and Occupational Therapy specialty measure set. These changes are in table B.33 of Appendix 1 of the proposed rule. CMS is also creating for the first time both a speech-language pathology and audiology specialty measure set, which are in tables B.42 and B.43 of the proposed rule. Promoting Interoperability Performance Category The promoting interoperability (PI) category encourages clinicians to use electronic health records and other electronic methods in their practices. MECs can earn up to 100 points based on the extent to which their practice incorporates certain objectives, which is then weighted into the final score. It’s important to note there are a number of exceptions to this category that will result in the score being reweighted to zero percent for certain MECs, as described below. This category was previously referred to as the “advancing care information” category. CMS allows physical therapists, occupational therapists, and speech-language pathologists to have the PI category reweighted to zero if these providers report zero PI measures. In addition, small practices or practices without Internet or other uncontrollable circumstances can claim a hardship exemption and have the PI score reweighted to zero. CMS also reweights this category to zero for clinicians who are considered “hospital-based.” Hospital-based MECs are those who furnish 75% or more of their services at Point of Service (POS) Codes 21 (inpatient hospital), 22 (on-campus outpatient hospital) or 23 (emergency room). CMS has not included POS 61, which indicates the service is provided at an inpatient rehabilitation facility, and has also not included other post-acute care (PAC) facilities, such as skilled nursing facilities (SNFs). Last year, AMRPA encouraged CMS to begin including POS 61 in its hospital-based definition, but CMS declined to do so. CMS is proposing to change how it defines and reweights hospitalbased groups. Currently, 100% of the group members need to meet the definition of a hospital-based MEC to have the groups score reweighted. CMS now proposes that only 75% of the group would need to meet this standard. Cost Performance Category In broad terms, the cost performance category evaluates MECs on the costs associated with their patients’ care when compared to peers. The cost information comes to CMS via Medicare contractors who process claims. The cost score is converted to a

AMRPA Magazine / October 2019 25

final numeric input towards the MEC’s total MIPs score. It should be noted that the cost category uses specific services such as evaluation and management (E/M) services to attribute cost to a certain clinician. Because occupational and physical therapists, as well as several other types of clinicians, do not bill these types of services, the cost score for these clinicians is weighted at zero. For most MECs, cost performance is determined by two metrics: the Total per Capital Cost measure, and the Medicare Spending per Beneficiary (MSPB) measure. The cost category performance period is the entire calendar year of the performance year, so cost will be measured based on all Part B Medicare patients treated during the entire calendar year of the performance year. CMS also has eight episode-based cost measures, but they are only applicable to a limited number of clinicians. The current episode based measures include: CMS is proposing several new episode-based measures, which include: 1. Acute Kidney Injury Requiring New Inpatient Dialysis 2. Elective Primary Hip Arthroplasty 3. Femoral or Inguinal Hernia Repair 4. Hemodialysis Access Creation 5. Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation 6. Lower Gastrointestinal Hemorrhage 7. Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels 8. Lumpectomy Partial Mastectomy, Simple Mastectomy 9. Non-Emergent Coronary Artery Bypass Graft (CABG) 10. Renal or Ureteral Stone Surgical Treatment Improvement Activities Category Under the improvement activities category, MECs must attest to completing certain activities that earn points based on their weight as either medium (10 points) or high (20 points). Performance on improvement activities is not measured, so MECs only need to attest to the activities’ completion and do not need to achieve any particular result. Like the other categories, the final score for improvement activities is converted into a number out of a maximum of 40 points that contributes to the MEC’s total MIPS score. CMS is proposing to add several new improvement activities for providers to choose from, as well as modify and remove more than 20 measures. Appendix 2 of the proposed rule contains a chart breaking down each activity and CMS’ rationale for the proposed change. 26 AMRPA Magazine / October 2019

CMS is also proposing changes to how groups participate in this category. Currently, only one provider in the group needs to attest to participating in an activity for a continuous 90-day period. Now, CMS proposes at least 50% of the MECs in the group would need to attest to completing the activity. In addition, 50% of the MECs must perform the same activity for the same continuous 90 days in order for the activity to qualify. Facility-based Scoring CMS currently allows MECs it defines as “facility-based” to have the option to use their facility’s Hospital Value-based Purchasing (VBP) Program scores as a total substitute for the MIPS quality performance and cost performance scores. For MECs that qualify as facility-based, there are no reporting requirements under the quality and cost performance categories. The VBP score for the MEC’s affiliated hospital is translated to the quality and cost score for the MEC using a percentile calculation. If a facility-based MEC chooses to submit quality measures, CMS will use those quality measures for MIPS scoring purposes if it will result in a higher score for the MEC, but otherwise will use the VBP score. To be eligible to qualify as a facility-based MEC, a clinician must furnish 75% or more of services at POS codes 21 (inpatient hospital), 22 (on-campus outpatient hospital) (POS code 22), or 23 (emergency room). At AMRPA’s urging, CMS sought information on how it could include post-acute care (PAC) settings of care in the definition of a facility-based MEC. AMRPA recommended to CMS that it allow Inpatient Rehabilitation Facility (IRF)-based clinicians to use their hospitals’ IRF Quality Reporting Program (QRP) score to substitute for the cost and quality measures. CMS responded that because the VBP program is a pay-for-performance, as opposed to the IRF QRP’s pay-for-reporting structure, it was appropriate to use the VBP but not the IRF QRP for MIPS purposes. Therefore, CMS did not include IRF-based clinicians (POS code 61) in the definition of facility-based, and also did not allow for the IRF QRP to substitute for the cost and quality performance measures. CMS says in this year’s proposed rule it is continuing to seek information on how to best include PAC settings in the facility-based definition. Performance Thresholds MIPS has a “performance threshold” that is the score a MEC must achieve to avoid a negative payment adjustment and achieve earn a neutral or positive adjustment. For 2019, the threshold was set at

30 points out of the 100 possible points. This year, CMS proposes to raise the threshold to 45 points. In addition to the standard performance threshold, there is also an exceptional performance threshold. CMS has a pool of $500 million, in addition to the MIPS payment adjustment, to give to “exceptional performers” under MIPS. In 2019, CMS set the exceptional performance threshold at 75, and is proposing to raise this threshold to 80 for 2020. CMS Estimates of MIPS Payment Adjustments CMS estimates for 2020, 87.3% of MIPS eligible clinicians that participate in MIPS are expected to receive positive or neutral payment adjustments. This figure excludes clinicians who are expected to receive a negative payment adjustment as a result

of failing to report MIPS data. In addition, since the distribution of payments is budget neutral, and CMS is retaining a relatively low threshold to avoid a negative payment, CMS estimates the maximum upwards adjustment a provider will be eligible to receive is 5.8%. CMS has further broken down the estimated payment adjustments by practice size in the chart below. Several AMRPA Committees are examining and developing responses to the Quality Payment Program and other proposals found in this rule. Future issues of AMRPA Magazine will feature some of AMRPA’s responses.

AMRPA Magazine / October 2019 27

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AMRPA Submits Comments to CMS Request for Information on Reducing Provider Burden On August 12, following a Request for Information (RFI) from the Centers for Medicare and Medicaid Services (CMS), AMRPA submitted extensive comments on how the agency could lessen the administrative burden on clinicians and other staff in inpatient rehabilitation hospitals and units (IRFs). CMS’ Patients Over Paperwork initiative seeks to eliminate unnecessary “red tape,” by improving reporting and documentation requirements, prior authorization procedures, dual-eligible requirements and documentation, and coding requirements for payment. Following discussions with members, AMRPA provided a number of recommendations to CMS that would decrease the administrative burden on IRFs, including elimination or amending of IRF classification criteria, elimination or streamlining of redundant clinical documentation requirements, modernization of IRF intensity therapy requirements, limitation of use of prior authorization by Medicare Advantage plans, reduction in administrative burden in the Medicare audit and appeals system, and several others. Additionally, AMRPA and the Acad emy of Physical Medicine and Rehabilitation (AAPM&R) issued a joint letter to CMS in response to the RFI. Reproduced below is an abbreviated summary outlining AMRPA’s key recommendations to CMS. The comment letter in its entirety can be found on the AMRPA website. Introduction IRFs occupy a unique space in the settings of care available to patients. In addition to offering an intensive array of therapy modalities and other rehabilitation treatments, IRFs provide hospital-level medical care, which is significantly different from the rehabilitation or general medical supervisory services provided in non-hospital postacute care (PAC) settings. Medicare beneficiaries admitted to IRFs for their immediate post-acute care have significantly better outcomes across a range of quality indicators compared to clinically matched beneficiaries who received their immediate post-acute care in another setting. These indicators include returning home from their initial stay two weeks earlier, remaining home significantly longer, utilizing emergency visits at a lower rate and experiencing a lower all-cause mortality rate.1 Despite their position as a highly effective and efficient PAC delivery system for Medicare beneficiaries, IRFs are arguably the most heavily regulated provider in all of Medicare. As this letter details, IRFs are subject to regulations that impact the specific diagnoses that they can treat to qualify as an IRF, the timing and form of how clinical team members meet to discuss their patients, the modes and exact number of hours of 1

ee Dobson Davanzo & Associates, Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities (IRFs) and After S Discharge (July 2014).

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therapy to be delivered, the soon-to-be 36 pages of assessment documentation that must be completed for every Medicare patient, and many others. These requirements exist despite the fact that IRF patients are supervised at all times by trained rehabilitation physicians, who may find their clinical judgment on the best course or method of treatment superseded by the need to meet these strict regulatory requirements. AMRPA members wrestle daily with understanding and complying with the vast web of overlapping regulatory criteria governing IRF admissions and patient stays. These extensive regulations, differing interpretations, conflicting contractor policies, regular audits and drawn-out appeals have all led IRFs to spend enormous amounts of time, resources and focus on administrative matters that are more appropriately spent on patient care. This enormous compilation of requirements is why AMRPA is fully committed to assisting CMS with its “Patients Over Paperwork” initiative, to better enable providers to deliver patient-centered care and the best possible outcomes for beneficiaries. The recommendations contained in our comments reflect extensive feedback from the medical rehabilitation industry, including professionals involved in every aspect of the treatment of IRF patients who possess a thorough understanding of the impact that specific policies and regulations are having on IRFs and their patients. I.

he Current IRF Classification Criteria Contains a Decades T Old Rule That Overrides Physician Judgment and Modern Medical Practice and Should be Repealed or Modified. Unlike other hospitals participating in Medicare, in order for IRFs to receive payment under their prospective payment system, they must admit a patient mix that fits a very specific criterion. Known as the “60% Rule,” the regulation mandates that 60% of all IRF patients must have diagnoses derived from 13 medical conditions.2 These 13 conditions are extremely outdated, having been expanded only once since their inception in 1975 (from 10 to 13 conditions), and therefore limit IRFs’ ability to evolve with the ever-changing medical treatment landscape. A. T he 60% Rule Is Inherently Flawed and Should Be Repealed to Allow Physicians and Modern Medical Standards to Dictate Treatment Decisions. The existence of the 60% Rule forces IRFs to meticulously monitor the diagnoses of admitted patients and screen those being considered for admission in order to comply with the rule’s provisions, thereby disproportionately emphasizing diagnosis rather than the patient’s rehabilitative and medical needs. In presupposing that patients with particular diagnoses require IRF services, the 60% Rule creates an incorrect impression that patients whose diagnoses fall outside of its diagnostic categories and medical conditions do not require IRF services. AMRPA recommends

2 3

CMS eliminate the 60% Rule as one of Medicare’s classification criterion for IRFs. The rule’s arbitrary assumptions supplant the medical judgment of physicians discharging their patients from general acute-care hospitals to IRFs, as well as physicians in IRFs when deciding whether to admit patients into their hospital. The rule effectively forces physician judgment regarding a patient’s rehabilitation placement to be secondary to Medicare regulations, and is therefore best characterized as top-down medical decision-making via regulation. II. I f CMS is Unable to Completely Withdraw the 60% Rule, the Agency Should Significantly Amend the Rule. If CMS finds itself in a position of being unable to repeal the rule, CMS should at the very least significantly alter the rule to allow for a more patient-centered approach to care. A. C MS Should Expand the Conditions Covered by the 60% Rule CMS should include conditions that have seen an increased need for intensive rehabilitation services due to changes in treatment norms and expected health outcomes. For example, while orthopedic conditions have seen a sharp decrease in need for IRF stays due to advancing technologies, improved outcomes for cardiac and pulmonary conditions have increased the need for those patient groups to be treated in an IRF. A. CMS Should Significantly Reduce the 60% Rule’s Threshold AMRPA notes that CMS has clear authority under statute to make this change, as the Medicaid, and SCHIP Extension Act of 2007 directs CMS to “require a compliance rate that is no greater than the 60% compliance rate that became effective for cost reporting periods beginning on or after July 1, 2006.”3 Therefore, while CMS may not increase the compliance threshold above 60%, the agency can clearly reduce the threshold percentage through notice and comment rulemaking.

B. C MS Should Lower the Medicare Threshold for the 60% Rule’s Presumptive Compliance Methodology and Other Suggestions AMRPA offers several suggested changes to the presumptive compliance methodology, including ways to ensure that future updates are made in a more constructive and collaborative manner. These include: removal of the 50% Medicare patient threshold to qualify an IRF under the presumptive compliance methodology; creation of a Technical Expert Panel (TEP) to provide input before making proposed changes to the ICD-10-CM codes; and provision of data that would allow IRFs to review the data associated with their presumptive compliance calculations.

42 C.F.R. § 412.29(b)(2). 4 Medicare, Medicaid, and State Children’s Health Insurance Program Extension Act of 2007, Pub. L. No. 110-173, § 115(b), uncodified 42 U.S.C. § 1395ww note.

AMRPA Magazine / October 2019 31

II. C MS Should Eliminate or Streamline Documentation Requirements for IRF Claims, Especially Those That Include Mostly Redundant Information A. Duplicative Documentation Requirements IRFs are subjected to significantly redundant documentation requirements, with stringent submission deadlines, that include a Pre-Admission Screen (PAS), a Post-Admission Physician’s Evaluation (PAPE), and an Individual Overall Plan of Care (IOPC). CMS should eliminate this duplication (and for certain data, triplication) in one of two ways. First, and most effectively, the agency can simply eliminate the redundancies in the patient assessment documentation criteria. This would be a truly meaningful deregulatory action that would not just avoid technical claims denials, but would actually reduce the time and cost burden associated with submitting each claim. At the very least, we recommend that CMS restrict the overreaching practice of denying entire claims for technical documentation deficiencies, such as one missing piece of information in one of the assessments, when that information is readily available or discernible from another part of the documentation for that claim. In the alternative, the agency could direct contractors to deem documentation for a single assessment to satisfy each of the assessments for that patient. Thus, if an IRF submitted documentation that satisfied identical requirements of the PAPE and IOPC for only one and not the other, the contractor would be required to accept the documentation for purposes of both assessments. B. C MS Should Provide Additional Flexibility for Arbitrary Time Requirements, Especially on Weekends and Holidays There are two major unnecessary timeline burdens placed on IRFs that could be alleviated with small changes to the CMS regulations: (1) establishing timerelated requirements in days, rather than hours, to avoid arbitrary cut-off periods during a workday, and (2) offering greater flexibility for documentation timeframes during weekends and holidays.

First, CMS uses a 48- and 24-hour standard for the PAS and PAPE, respectively. If CMS were to rephrase these regulations as a “day” standard, it would go a long way to alleviate pressure on IRFs to correctly time their documentation submissions. If CMS’ deadline for the PAPE were instead phrased as “midnight the next calendar day,” rehabilitation physicians would not be caught in the position of having to interrupt direct patient care in order to fill out and submit documentation by a rigid deadline having nothing to do with patient quality or outcomes. CMS should 4

implement this same change for the deadlines applicable to the PAS and IPOCs so providers are not required to fixate on exact times. Second, we ask CMS to allow certain flexibility for deadlines on weekends and holidays. CMS could add a clause to its regulations to require that the documentation be completed within 24 hours, or by the end of the next business day, whichever is later. This would allow providers to focus on the most pressing needs of patients and complete the PAPE during the next business day, if clinically appropriate. III. C MS Coverage Rules for the Delivery of Therapy in IRFs is Overly Restrictive and Confusing, Leading to Unnecessary Burden and Curbing Access to Needed Therapies A. T he Therapy Intensity Requirements Should Be Updated to Allow For Patient-Centered Care Delivery Clinicians, and not regulators, should dictate the manner, mode and timing of therapy services based on the individualized needs of a patient. Therefore, CMS should do away with the overly restrictive hour and mode requirements and instead require a generally intensive course of therapy to be delivered in the manner or mode decided by the clinician. This change could be accomplished by revising the current regulations or guidance to require 15 hours per week of therapy, delivered in the manner and mode justified by the clinician in the medical record.

B. T he Restrictions on the Types of Therapy in an IRF Should Also Be Relaxed to Allow for the Best Possible Outcomes for Patients CMS should expand the types of therapy permitted to count towards the therapy intensity requirements so that clinicians, and not CMS, determine the best course of treatment for patients. Other types of skilled therapy, such as recreational therapy, should be counted as a qualifying modality when it is: (1) prescribed by the treating physician and the rehabilitation team as part of the patient’s plan of care; (2) considered active treatment; and (3) provided by a qualified therapist. Other services that should be considered include psychological and neuropsychological services.

IV. P roposals to Reduce Burden Resulting from Medicare Advantage Practices IRFs find that Medicare Advantage (MA) plans are placing an untenable burden on IRFs through their prior authorization processes. According to membership reports, an inordinate number of prior authorization requests for IRF services are initially denied.4 These denials set off an appeals process that is time-consuming and takes physicians away from delivering patient care, thereby delaying access to needed care for beneficiaries. To address this issue, we propose

edicare Payment Advisory Commission, Report to The Congress: Medicare Payment Policy 298 (Mar. 2017) (Finding that MA beneficiaries are admitted M to IRFs at a rate nearly three times less than traditional Medicare beneficiaries).

32 AMRPA Magazine / October 2019

that CMS bar MA plans from using a prior authorization program for IRF services. CMS should require MA plans to align their requirements with the fee-for-service program and review claims on a post-service basis. In addition to lessening administrative burden, this would also ensure that MA beneficiaries are not inappropriately denied access to services to which they are medically qualified and legally entitled.5 At the very least, we ask CMS to implement the following guardrails to both protect vulnerable rehabilitation patients and lessen burden on IRFs. 1. R equire a Physician with Specialized Training and Experience in Rehabilitation to Make Prior Authorization Determinations Rehabilitation physicians report they spend an outsized amount of their time on the phone with MA plans justifying admission decisions. Making IRFs jump through administrative hoops to have MA plans without expertise overruling medical judgment is an unsound and clinically dangerous policy. To save time and ensure accurate decisions are reached, CMS should require that only a clinician with specialized training in rehabilitation be utilized to review prior authorization requests. For “peer-to-peer” discussions, this should include a physician that meets Medicare’s definition of rehabilitation physician and would be appropriately qualified to themselves serve the rehabilitation physician role.

2. P rohibit the Use of Proprietary Decision-Making Tools by MA Plans MA plans often utilize propriety guidelines, such as those marketed by Milliman and Interqual, to justify denying patients’ access to IRFs. In our members’ experience, these guidelines recommend upwards of 95% of cases qualifying for IRF care be directed to a lower-intensity setting, such as a skilled nursing facility (SNF). This practice runs contrary to CMS coverage guidelines, which requires MA plans to offer the same level of care to its patients as traditional Medicare. 6

3. M andate MA Plans Issue More Timely Decisions and Be Staffed at All Hours to Handle Pressing Prior Authorization Requests Despite the vulnerable state of patients in hospitals, MA plans typically take several days to render decisions, and their operations often cease in the early evenings and on weekends. If private health plans choose to participate in the Medicare Advantage program, these plans should have 24/7 availability of qualified clinical personnel to timely consider prior authorization requests as well as appeals of negative prior authorization determinations.

V. H HS and CMS Should Revamp Audit, Denials and Appeals Procedures A. CMS Should Take Steps to Eliminate Technical Denials. CMS should include a statement in regulations governing IRF coverage rules and contractor audits declaring that isolated technical deficiencies in documentation shall not constitute the sole basis for denial of a claim. Alternatively, the agency could establish a “totality of the circumstances” test for determining whether coverage criteria are met. This change would prevent entire claims from being denied for many of the more perfunctory reasons, such as one missing signature next to a note or documenting the post-admission evaluation one hour late (unless they are systemic or can otherwise be shown to impact patient care). B. C MS Should Improve Audit Processes To Facilitate Improved Performance and Lessen Burden on Providers AMRPA appreciates that CMS recently issued a set of standardized denial codes to be used by all contractors when reviewing claims from facilities being paid under the IRF PPS.7 However, AMRPA remains concerned that without a requirement that contractors cite the specific deficiency found in the medical record, providers may still be unable to determine their error and thus not be able to improve performance. Further, we also recognize that CMS has implemented the Targeted, Probe and Educate audit procedures, which are geared towards providing education to providers to explain the reasons for denials of specific claims. However, it has been AMRPA providers’ experiences that the education portion of this process is lacking. Beyond the deficiencies in the education sessions, it is unclear that these probes are truly as “targeted” as they are meant to be. At the very least, CMS should provide more transparency as to how providers are chosen for the probe and focus on one problem area in particular (for example, physician visit documentation or on therapy notes).

Finally, the frequency of audits creates an unreasonable burden on providers. CMS should limit audits to once per year per provider, and longer for providers who have demonstrated high compliance rates. C. T here are Simple Ways HHS Could Streamline the Appeals Process to Alleviate Provider Burden In order to shorten the lengthy Medicare appeals process, reduce provider burden, and hasten the time to final resolution, CMS should consolidate the redetermination and reconsideration stages of the appeals process. At a minimum, providers should be

edicare Managed Care Manual Chapter 4. Revision 121, Issued: 04-22-16 (“While an MA plan may offer additional coverage as a supplemental benefit, it M may not limit the original Medicare coverage. MA plans must provide their enrollees with all basic benefits covered under original Medicare.”).

Medicare Managed Care Manual Chapter 4. Revision 121, Issued: 04-22-16.

I npatient Rehabilitation Facilities Reason Codes and Statements (Updated December 8, 2017). Retrieved from: https://www.cms.gov/Research-StatisticsData-and-Systems/Computer-Data-and-Systems/ESMD/Downloads/Inpatient-Rehabilitation-Facilities-IRF.pdf.

AMRPA Magazine / October 2019 33

allowed to opt out of the reconsideration stage before proceeding to ALJ review. D. C MS Should Halt Recoupment of Claims Denied PostPayment Through the Issuance of an ALJ Decision In order to lessen the financial strain imparted by the current appeals process, and to spare CMS compounding interests costs, CMS should expand the current limitation on recoupment related to postpayment denials through the date an ALJ decision is issued. This proposal would alleviate some of the financial burden borne by providers stuck in the yearslong appeals backlog by allowing them continued access to reimbursement for care already furnished.

E. C MS Should Create an Audit “Circuit Breaker” to Stop Unnecessary Audits Medicare contractors should be barred from conducting payment reviews based solely on statistical analyses when a provider demonstrates why its caseload is at variance with the applicable regional or national analyses. In recent years, Medicare contractors have increasingly audited cases citing statistical analysis as their rationale. In reality, the multitude of factors that influence individualized post-acute care placement decisions are not conducive to an oversimplified audit-by-number approach. In the end, such statistical analyses simply demonstrate variation from a mean, and can signal exceptional clinical performance - not improper practices.

MS Should Require Recalculation of Error Rates for C Providers Under Pre-Payment Review Medicare Administrative Contractors (MACs) that institute ongoing pre-payment reviews against a provider should be required to recalculate providers’ error rates on a quarterly basis (and include the results of any favorable appeals in the calculation) for purposes of determining whether it is appropriate to continue pre-payment review or revise the percentage of claims to be reviewed. While pre-payment review can help identify improper payments before they are made, it also creates significant administrative inefficiencies if it fails to account for appeal outcomes, continuously shuttling new denials into the appeals system.

G. C MS Should Deem Appealed Claims as Payable if They Remain Pending for Five Years or More After the Initial Determination. If any appeal is still pending five years after the date of the initial determination on the claim, the claim should be deemed payable. By presuming that after a certain period of time a claim should be considered finally decided, this proposal is consistent with reopening regulations treatment for claims not involving allegations of fraud or similar fault.

VI. E lements of The IRF Quality Reporting Program (IRF QRP) Should Be Revised to Provide the Most Clinically Relevant Data and Ensure Minimal Provider Burden. As CMS continues to implement the quality measures and data collection requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, we urge it to do so in a practical and minimally burdensome manner that adds value to post-acute care providers and to patients. This approach would be consistent with the goals of “Patients Over Paperwork” and “Meaningful Measures” to reduce provider administrative burden (specifically with regard to burden from quality measures) and ensure that federal reporting mandates prioritize actionable, patient-centered information. A. C MS Should Prioritize Clinical Utility and Patientfacing Value in Developing New Standardized Patient Assessment Items Pursuant to the IMPACT Act AMRPA is concerned that the standardized patient assessment data elements (SPADEs) add significant provider burden and it is unclear how many of the data items would actually improve the efficiency and quality of post-acute care. To meet the IMPACT Act’s requirements, CMS should consider an approach by which it implements a core set of non-duplicative standardized patient assessment items across all PAC settings, upon which it builds and supplements settingspecific assessment items as needed. AMRPA urges CMS and its contractors to prioritize and consider in concert both the administrative burden to providers of collecting data and the data’s clinical effectiveness and utility.

B. C MS Should Account for the Added Reporting Burden in FY 2021 CMS estimates that the new SPADEs will add approximately 20 minutes to each patient assessment, at a minimum. CMS must recognize that any addition, revision, or adjustment to the IRF-PAI has a considerable ripple effect in terms of increased burden on providers’ operations. AMRPA urges CMS to account for the costs associated with the finalized IRF QRP additions by upwardly adjusting the IRF PPS payment update in the FY 2021 rulemaking to reflect higher provider resource use (and therefore costs).

C. C MS Should Lower the IRF QRP Completion Threshold in FY 2021 The IRF QRP completion threshold is 95%. In contrast, the SNF QRP and LTCH QRP completion thresholds are 80%. AMRPA urges CMS to propose a reduced IRF QRP threshold percentage that is aligned with other PAC QRPs (i.e., 80%) in FY 2021 rulemaking and prior to the October 2020 implementation of the new SPADEs. At a minimum, the IRF QRP completion threshold should be lower than 95% in the first year providers are required to report the new SPADEs.

34 AMRPA Magazine / October 2019

D. T he 2% Payment Penalty for Failure to Successfully Submit Required Quality Data Should Provide Flexibility for Providers Who Make a Good-Faith Effort to Submit AMRPA continues to ask CMS to provide flexibility in its application of the IRF QRP payment penalty for IRFs that make a good-faith effort to comply and submit quality reporting data. Due to the volume of mandatory reporting items, the unreasonably high likelihood of reporting errors (particularly through the National Healthcare Safety Network [NHSN]), and lack of a confirmatory checkpoint, the inflexible and outsized financial penalty should be reexamined. AMRPA urges CMS to provide more flexibility in its application of the noncompliance penalty to allow providers an opportunity to correct any errors when a good faith effort to submit data is undertaken. Correspondingly, we ask that CMS reserve harsher penalties for egregious offenders who fail to consistently submit IRF QRP data in a timely or thorough manner. E. C MS Should Remove Measures That are Not Clinically Relevant to IRF Quality of Care from Mandatory Reporting and From Public Display As described above, the NHSN measures in particular are administratively taxing to report and the provider costs associated with these measures can be severe and disproportionate to the limited value these measures bring. Therefore we recommend that CMS act to remove the following measures from the IRF QRP: • NHSN Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138); • NHSN Facility-wide Inpatient Hospital-onset Clostridium Difficile Infection (CDI) Outcome Measure (NQF #1717); and • Influenza Vaccination Among Health Care Personnel (NQF #0431), which is also submitted via CDC/ NHSN.

VII. CMS Should Allow IRFs the Flexibility to Maximize Their Participation in Alternative Payment Models (APMs) to Innovate Care Delivery. A. C MS Should Allow IRFs to Implement Alternative Pricing within APMs. An increasing number of APMs hold provider entities, such as acute care hospitals or broader networks of providers, responsible for post-acute spending. These models encourage IRFs, like other post-acute care providers, to produce high-quality outcomes at a reduced cost. However, unlike other post-acute providers such as nursing homes, IRFs are paid on a flat per-discharge basis for patients. For IRFs to be able to compete alongside other providers in these models, CMS should allow willing providers permitted to receive reduced reimbursement, a per diem payment, or offer a discount from the IRF PPS amount, if they so choose.

B. CMS Should Offer Regulatory Waivers for IRFs in APMs CMS should afford IRFs the option of including patients admitted under an APM as counting towards the IRF’s compliance with the 60% Rule. Innovations and advances in medicine over the past four decades have enabled patients with other serious diagnoses to not only survive acute care hospitalizations, but to also benefit tremendously from the intensive and multidisciplinary rehabilitation program provided in IRFs. However, these patients are often denied admission because they do not meet 60% Rule compliance. C. C MS Should Allow for an Administrative Presumption of Coverage Under APMs All patients admitted to IRFs from acute care hospitals participating in an APM, regardless of whether the provider is receiving IRF PPS payment or reduced reimbursement, should be presumed to be covered in the IRF setting. CMS should instruct its contractors to respect post-acute care referrals and admission determinations under APMs. Specifically, CMS’ contractors should not be permitted to deny payment for cases treated under APMs based on pre-payment review or post-payment reopening, unless there is evidence of fraud.

D. CMS Should Test APMs That Aim to Directly Demonstrate the Clinical and Financial Value of Regulatory Flexibility AMRPA urges CMS, via the Center for Medicare and Medicaid Innovation (CMMI), to test a model specifically designed to show how relief from certain regulatory requirements applicable to IRF physicians that could both reduce Medicare expenditures and improve patient care – precisely in line with the goals of all CMMI models. To that end, AMRPA asks that CMS consider developing a new set of billing codes that would be used by an attending rehabilitation physician for daily care for an entire inpatient rehabilitation episode.

E. C MS Should Voluntarily Test Any Unified PAC Payment System Before Submitting a Prototype to Congress The IMPACT Act of 2014 directs the Secretary of HHS to develop a technical prototype for a unified PAC PPS and submit it to Congress along with accompanying policy recommendations. Before such a prototype and policy recommendations are submitted to Congress, HHS must pilot or test the prototype payment system in order to ascertain the feasibility of its implementation and use within the PAC sector, including its capacity to predict patients’ PAC resource needs and impact on patients’ quality of post-acute care and outcomes. Such a pilot or test should be voluntary, should be designed to accommodate the testing of multiple payment and reimbursement methodologies (including episodic and stay-based payment reimbursement approaches) and provider reimbursement rates contemplated under the prototype, and should include waivers or rescissions of site-specific regulations and policies that define current post-acute provider settings.

AMRPA Magazine / October 2019 35

VIII. CMS Should Change Its Policy on New IRFs to Reduce Undue Administrative Burden Many AMRPA members perceive CMS’ current policy for paying new rehabilitation units as placing a sizable and unnecessary burden on hospitals attempting to open a new IRF subunit. Currently, if a unit opens before the first day of a cost report period, the unit is paid on the basis of an acute hospital’s diagnosis-related group (DRG) instead of the corresponding IRF case-mix group (CMG) for the remainder of the cost-reporting period. Because the lower reimbursement rate from DRGs is not adequate for an IRF to sustain itself, new hospital-based rehabilitation units are all but required to open on, or a day or two prior to, the hospital’s cost report year. Paying hospital-based rehabilitation units under the IRF PPS’ CMGs from the outset, the same as a freestanding rehabilitation hospital, is a simple fix that harmonizes the payments across all new IRFs. IX. R ecommendations to Reduce Patient and Family/Caregiver Burden in Navigating Post-Acute Care CMS should encourage earlier discussions in the acutecare hospital setting that educate beneficiaries and their families/caregivers about discharge planning needs and post-acute care. This decision should also include educating the patient’s family or caregiver about post-discharge needs, such as assistance with activities of daily living, as assessing caregivers’ ability to support these needs is highly informative to PAC discharge planning. Many families and caregivers would benefit from being more aware of PAC patient needs and potential options earlier in the patients’ care trajectory. CMS should also revise hospital discharge planning requirements to facilitate more transparent dialogue between hospitals discharge planners and patients about PAC. Finally, CMS should enhance transparency and improve beneficiary education regarding what Medicare covers for post-hospital care, the difference in covered services across PAC settings, and the differences in beneficiary cost-sharing responsibilities across settings. X. C MS Should Amend Hospital Conditions of Participation and Enrollment Requirements The rehabilitation hospital sector has long been at the forefront of care innovation and improvement for PAC patients. Among the sites of care in the PAC continuum, which include LTCHs, IRFs, SNFs and home health agencies (HHAs), IRFs enjoy the unique distinction of being the site of care that delivers both intensive rehabilitation services and hospital-level medical care. AMRPA has several recommendations that would lessen provider burden and allow IRFs to remain competitive with other post-acute care providers. These would involve changes to the Medicare Conditions of Participation (CoPs) and HwH regulations to facilitate an existing IRF incorporating an LTCH into an existing hospital site. A. C MS Should Amend the Medicare Conditions of Participation to Alleviate Burden on Existing IRFs AMRPA recommends CMS amend these regulations to allow for more parity across PAC hospitals and to eliminate outdated co-location standards that

serve no clinical purpose. The changes CMS makes should include allowing for more lenient separateness standards for co-located hospitals when both hospitals are IPPS-excluded hospitals. Additional changes should also include permitting medical staff and other clinicians, such as therapists, to move more freely between the two hospitals, especially when patients are transitioned from one hospital to the next during the course of the patient’s recovery. CMS should also allow other crossovers, including integrated medical records and other clinically related services that benefit a patient when they remain consistent through the patient’s course of treatment. Administrative functions such as billing, payroll and accounting should also be permitted to be shared between the two entities. In addition, the agency should loosen shared space restrictions, permitting families to share specialized treatment areas and other clinical areas that may benefit patients at both hospitals. B. C MS Should at Least Create a Grandfather Exception for Previously Existing HwHs AMRPA requests that if CMS cannot amend the CoPs as described in the above subsection, that CMS at the very least include a narrow “grandfathering” exception for specific cases where the current configuration does not meet CMS standards for HwH separateness. This exception process is necessary where the ability to reconfigure a hospital building may be cost prohibitive, and hospitals would be closed if not provided an exception. Providers are more than capable of addressing privacy, quality and safety concerns in shared space, and should be permitted to do so when granted grandfather status. *** In conclusion, IRFs offer life-changing care to patients that have been afflicted with a serious injury or illness. The recent regulatory changes – as well intentioned as they may be – have put IRFs in a precarious situation. AMRPA appreciates the opportunity to participate in CMS’ important efforts to streamline Medicare policies to prioritize patient care. We are also eager to provide any technical assistance or further information on our recommendations at your convenience and look forward to continuing to collaborate on creating a more patient-centered health care delivery system. If you have any questions, contact Kate Beller, AMRPA Executive Vice President for Policy Development and Government Relations (202-207-1132, kbeller@amrpa.org). Sincerely,

36 AMRPA Magazine / October 2019

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Don’t Miss Out On the First Ever AMRPA Congressional Outreach Boot Camp AMRPA will be hosting its first ever Congressional Outreach Boot Camp on October 13 in San Diego before the start of the 2019 Fall Educational Conference & Expo. This pre-conference course is designed to coach attendees on how to successfully engage your members of Congress, set up meetings and tours, use AMRPA resources and talking points, and most importantly, advocate on behalf of the medical rehabilitation field. Get ready to join the AMRPA advocacy effort with our expert government relations team, as they review AMRPA’s top policy priorities and prepare you to champion for medical rehabilitation and the patients you serve. Grassroots advocacy in our industry has never been more important – this session will show you everything you need to know. AMRPA spoke with Martha Kendrick, Partner, Akin Gump Strauss Hauer & Feld LLP, and host of the Congressional Outreach Boot Camp, to get more information on this year’s program. 1. What can attendees expect from the Congressional Outreach Boot Camp? Attendees will learn why it is critical to form working relationships with their Congressional representatives, and how to hold an effective meeting with a member of Congress and/or their staff. Speakers will drill down on AMRPA’s policy priorities for the medical rehabilitation field, as well as discuss how to deliver an impactful message that resonates with members of Congress and compels them to take action. 2. What will the Congressional Outreach Boot Camp experience add to the Fall Conference experience? Political advocacy may seem daunting to some, but meeting with Congressional representatives can have a positive impact on your hospital and the medical rehabilitation field. Speakers will provide insight on what issues are currently driving the legislative process, and what you can expect Congress and the Trump administration to implement that will have an impact on your hospital and how you deliver care. Additionally, we will offer our view of participating in elections and how you can get involved. 3. What skills or knowledge will attendees walk away with? Speakers will teach you the do’s and don’ts of advocacy, and how educating members of Congress could help implement desired policy changes. 4. Who will benefit most from the Boot Camp? Anyone with a passion for providing post-acute care! 5. How did you select the speakers? The Boot Camp speakers have spent a significant time on Capitol Hill lobbying members of Congress and/or their staff, as well as administration officials, on a wide variety of health care issues. They also have substantial experience working with/for Members of Congress and federal agencies.

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AMRPA Political Action Committee (PAC) Seeks to Advance the Cause of IRFs

A political action committee (PAC) is a transparent, legal and federally monitored way for trade associations such as AMRPA to participate in the political process. The AMRPA PAC was formed to assist our efforts to educate political leaders on the value of medical rehabilitation in their communities. As an AMRPA member, your voice is a vital part of that message and it enhances the effectiveness of the medical rehabilitation fieldâ&#x20AC;&#x2122;s political advocacy efforts. By voluntarily contributing to the PAC, AMRPA members are able to pool their resources to help elect qualified members of Congress whose views and voting records support the issues affecting the medical rehabilitation field. One hundred percent of your donation will be spent on political campaign contributions, as opposed to administrative and overhead expenses. As seen in the table below, in fiscal year (FY) 2019, the AMRPA PAC made contributions to 15 campaigns to further medical rehabilitationâ&#x20AC;&#x2122;s efforts. With your voluntary contribution, the AMRPA PAC will be able to increase the reach of medical rehabilitation advocacy. Member of Congress

40 AMRPA Magazine / October 2019

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AMRPA member organizations’ executive and administrative personnel who are paid on a salary basis and who have policymaking, managerial, professional or supervisory responsibilities, are eligible to make a voluntary contribution to the AMRPA PAC. Contributions to the AMRPA PAC will be used for political purposes, and must be drawn on personal, not corporate, accounts. Political contributions are not tax-deductible for federal

income taxes. Individuals in AMRPA’s membership, also known as the restricted class, may voluntarily contribute up to $5,000 per year to the AMRPA PAC. Contributions are voluntary – you may choose whether and how much to give to the AMRPA PAC. If you have any questions or would like to learn more about the AMRPA PAC, contact John Ferraro, AMRPA Executive Director, at jferraro@amrpa.org or 202-591-2469.

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AMRPA & eRehabDataÂŽ Have Your Back

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

Visit eRehabData.com to learn more, or contact Sam Fleming at sam@erehabdata.com to receive a free demo. Without losing any historical data, our staff help you migrate to the only patient assessment system that is trusted, owned, used, and supported by the medical rehabilitation industry. 48 AMRPA Magazine / October 2019