AMRPA Magazine September 2018 by AMRPA

September 2018 â&#x20AC;˘ Vol. 21, No.9

September is Membership Month

August 2018 • Vol. 21, No. 8

The official publication of the American Medical Rehabilitation Providers Association (AMRPA)

Table of Contents Letter from the Chair

In Tribute: Edward A. Eckenhoff

Legislative Update

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

Trump Administration Reshapes Private Insurance through Association Health Plans and Short- Term Plans

John Ferraro, MS AMRPA Executive Manager

Key Developments in Medicare Audits and Appeals

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

Common FIM Scoring Errors

CMS Issues FY 2019 IRF PPS Final Rule: Adopts Proposals to Move to New CMGs, Adds an Additional Year of Data Analysis and Eliminates the FIM™

FY 2019 SNF Final Rule Includes Major Changes for Nursing Home Payment System

MedPAC Issues 2018 Data Book on Medicare Utilization and Spending Trends

HHS Inspector General Finds Weaknesses in Medicaid Managed Care Organizations’ Fraud Prevention Efforts

CMS Releases 2019 Physician Fee Schedule Proposed Rule; Proposes Changes to Therapy Reporting and E/M Codes

CMS Releases 2019 Quality Payment Program Proposed Rule; Therapists to be Included in MIPS

AMRPA Submits Comments Regarding CMS’ Revised Pre-Claim Review Demonstration for Home Health Services

Mimi Zhang AMPRA Senior Policy and Research Analyst Patricia Sullivan AMRPA Senior Editor Lovelyn Robinson AMRPA Researcher and Editor Brian McGowan and Shirley Soda AMRPA Design and Layout

AMRPA Magazine, Volume 21, Number 9 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. Individuals who are employees of member institutions may subscribe to the magazine for $100 annually. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color. Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Samantha Schwarz, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1132, Email: sschwarz@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 ©2018 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Kellen Company. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 750, Washington, DC 20045

AMRPA Magazine / August 2018

Study Evaluates the Effectiveness of Medicare’s Bundled Payment Program on Medical Conditions Latest Research Findings

Madonna Rehabilitation Hospital Reduces Patient Falls by 21 Percent Using AHRQ’s Toolkit

Mobile Tablet-Based Therapy Following Stroke

Latest Research Findings

Federal Elections Center

Letter from the Chair

September is Membership Month September is membership month and for those who are current members of AMRPA, I hope that I don’t have to remind you of the value of membership. However, to me the value of membership includes: Advocacy: We have an aggressive commitment to monitor and advocate on federal legislation, regulations and policies affecting our field.

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

Education: Offer dynamic (or relevant) programming through various platforms that target operational, quality, regulatory, legislative, financial issues and training. Communication: Deliver timely information that could affect our field and develop platforms that facilitate the exchange of ideas and best practices. Research and Data: Develop reliable and cutting-edge technologies to deliver clinical and financial data and analysis through AMRPA’s eRehabData® platform. We also deliver facility-level market analysis on referral patterns to inpatient, post-acute care facilities through our Post-Acute Care Market Analysis Reports. This list is compelling but doesn’t tell the whole story of membership. The other crucial part of the story is the value the association receives from your commitment to our field. We see the value that you bring to the association, which includes: Shared voice: Together we speak with one voice when advocating. We work together to influence health policy in order to meet the needs of our patients and caregivers. At the same time we promote excellence in practice and fight for access to care. Networking and Shared Education: Promote the sharing of ideas, practices, marketing, operational and research initiatives to ensure that we remain relevant, strong and transformational in the face of a changing health care landscape. Gregg Stanley, chairperson of the AMRPA Membership Committee, has been quoted as saying, “AMRPA membership is a kind of insurance policy, one that safeguards patient access.” This committee has been working hard to grow our membership and to ensure that we speak for all our members including non-profit, for-profit, freestanding hospitals and hospital units, urban, rural, large, small and teaching hospitals. Our association needs your help in spreading the message about the value of AMRPA membership. A robust membership is critical to us, individually and collectively. If you know of a rehabilitation hospital/unit that is not a member, please contact AMRPA Member Services Coordinator Samantha Schwarz at sschwarz@amrpa.org or 202-207-1132. This effort will assist us in reaching out to them to discuss the value of membership. AMRPA is the nation’s only organization dedicated to inpatient rehabilitation hospitals and units – it is imperative that we continue to join together to speak for those who can’t speak for themselves.

AMRPA Magazine / August 2018

American Medical Rehabilitation Providers Association (AMRPA) Tribute to Edward A. Eckenhoff AMRPA mourns the loss of one of its founding leaders and champions, Edward A. Eckenhoff, who passed away on January 9, 2018. A visionary leader, Ed inspired and connected with every single person he met, from Presidents to the most vulnerable among us. In a most direct and real way he molded the formative culture and values of the American Medical Rehabilitation Providers Association (AMRPA), uncompromisingly challenging the organization to focus on primary mission of effective advocacy and access to complex rehabilitative services for persons with disabilities. In 1997, Ed and several other hospital CEOs decided to break off from another group, determining that the rehabilitation hospital field needed its own independent voice and organization in order to advocate more effectively and serve the interests of persons with disabilities. AMRPA was thus born and Ed served on its board of directors from its founding through 2010. He served as board chair in 2000 and 2001. Among his many achievements, Ed created and chaired the first Consumer Advocacy Committee for AMRPA, focused from the beginning on the needs of patients served by rehabilitation hospitals. Ed moved from the Rehabilitation Institute of Chicago to Washington, DC, in 1983 to found the National Rehabilitation Hospital (NRH) and opened its doors in 1986. Consistently ranked as one of the top medical rehabilitation hospitals in the country, MedStar NRH has served multiple thousands of persons with disabilities regain their lives. Ed Eckenhoff was both a man of grace and a force of nature. He faced enormous physical challenges from the moment he became paralyzed at the age of 20 but turned the lifetime disability challenges he faced into “ability” examples and moments, inspiring countless others. At a memorial service held on May 10, 2018, at The National Cathedral in Washington, DC, family, friends and colleagues gathered to celebrate Ed’s indelible spirit and gifts to all whom he touched. The AMRPA Board of Directors and our members extend heartfelt condolences to his wife Judi Eckenhoff and the team and community Ed built at MedStar NRH. Ed Eckenhoff’s legacy lives on and challenges each of us committed to the field of medical rehabilitation.

EDWARD A. ECKENHOFF March 4, 1943 ~ January 9, 2018

AMRPA Magazine / August 2018

The following remarks were given at Ed Eckenhoff's memorial service, May 10, 2018

Remarks on Ed Eckenhoff By John Rockwood It is an honor to be here with all of you to celebrate the remarkable life of Edward Eckenhoff. Five minutes will not do justice to Ed’s life and legacy, but then again, he always liked putting a bit of pressure on me. Although he is looking down on all of us today, probably wondering why it is not a much larger crowd, today’s attendance is testament to the fact that Ed had a gift of connecting with people; of making those around him feel as if they were his best friend. He had a way with us that was truly unique, and, in turn, we could not get enough of him (perhaps with the exception of Judi on occasion). He inspired us and taught us how to use barriers in life…whatever they may be…to our advantage. His disability was obviously life changing for him in so many ways, but not only did it not get in his way, it fueled him to accomplish what few others are capable of. In fact, he firmly believed that his accident put him on the path he was meant to travel, whether it was meeting the love of his life, Judi or founding the MedStar National Rehabilitation Hospital and Network. And I know he shared every success with his wife Judi, who was the most important thing in his life.

Team Members in the very the same way. Whether there was accomplishment or sorrow, he was the one that all of us ran to….from our housekeeping team to our medical staff. And he knew everyone at work by name…everyone! I miss our time on the golf course, especially those afternoons at of his favorite club when it was just Ed and me. No offense to all of our other golf partners, but I really did cherish those times alone with him. For 30 years I was fortunate to have spent more time with Ed than anyone (again, with the exception of Judi), and I just can’t put into words what he meant to me. He was, of course, my mentor throughout my professional life; he was often a surrogate parent, but he was always one of the most important people in my life…he was my best friend. • • •

I was in awe by how he could get people to follow him as a leader, or to simply help him on the few occasions he needed it. From his VIP status at the restaurants he frequented, to his buddies who caddied for him…folks in the airport, and his countless number of friends all jumped to his assistance; he was always grateful and it made us all feel good in the process. Many of you, like me, learned the true joy of golf from Ed. And at the end of the round many of us were on the other end of one of his signature phrases… “so, how does it feel to lose money to a cripple?” And most of us did. Those were his words…used with love and jest … to make us all feel worse about our own game and to teach us that winning in life is not nearly as important as living life to the fullest. I remember how happy it made him to be on the golf course, and that joy was infectious to the rest of us. He never took one round for granted. As he got a bit older, Ed would need some help getting out of the golf cart. The best way to do that was to grab his belt and pull him up. Towards the end of a round I can still hear Ed saying… hey Johnny, can you grab the belt! Of course, I would. And without fail, as soon as he was vertical it was a simple wink and then another signature phrase… “Yah Baby!”

January 9 was the day that Ed finally no longer needed crutches or braces. He found his peace. I have been fortunate to talk with many of you about what Ed meant to you, particularly those associated with NRH, to share our grief and the many stories we all have to remember him. •

• • •

• •

On the golf course and in life he treated everyone the same… he was so good with our patients who were in the early stages of injury or disability. Can you imagine what an inspirational conversation it would be coming from Ed? Someone who has experienced first-hand the struggles that they are going through, yet someone who truly succeeded in every way and was able to exude life and happiness in the process. He connected with our

Not a day goes by that am not reminded of Ed in some way. Not a day goes by that I don’t wish that I was able to pick up the phone and call him. Not a day goes by that I don’t reflect on his years of advice and wisdom. The phrase “do as I say and not as I do” seemed to come up quite a bit.

We all went through the shock of his actual death; we all new he was sick but somehow we tricked ourselves into thinking he would beat this like he did every other challenge he encountered in life. We are all sad, we all miss him, and we are constantly reminded of him We miss his leadership and his zest for life. We are in awe of his accomplishments and the sheer number of lives he touched - the thousands of staff and patients over the years, his friends from the industry, our Board Members, those who shared his love for antiques and porcelain, his golf buddies, my family…the list goes on. But most important, we are profoundly grateful to have had him in our lives And in the context of all of these emotions, I know he is in heaven and looking down on all of us. And until I see him again, I will remember him often, laugh at and reflect on my thousands of “Eddie” stories, celebrate his life and accomplishments, and miss him.

I know you will all do the same.

AMRPA Magazine / August 2018

Tribute to Edward A. Eckenhoff by Walter Eckenhoff I’m here to say a few words about the family side of Ed. I’m Walt, the middle brother. I can tell you that having such accomplished brothers as Ed, and his twin brother Ben before he passed away, on the older end and Rod on the younger end was terrific, but it didn’t leave a lot of air in the middle. All of you middle children out there might understand. Ed had many gifts. He was inspiring, courageous, strong, funny, and had this natural ability to engage people regardless of who you were. But mostly for us, he was about family. Loyal to the core and if you ever needed a champion on any particular day, he was always there. You were never better than when Ed was praising you. A little background. Ed and Ben were born during the war. And Rod and I came along post war. So in a family long on discipline (the right kind, I might add), emphasizing respect, hard work and education, Ed blazed the trail for Rod and I by making all the mistakes first. Growing up, Ed was an accomplished athlete – big, strong, fullback on the high school football team, co-captain with brother Ben of the track team, good tennis player, accomplished swimmer/lifeguard and excellent water and snow skier. As many of you know, he waterskied after his accident – a feat few have attempted and he did it with full understanding that the 30 pounds of steel on his legs were not going to help him float when he fell. What many of you may not know is that Ed was also fluent in German and he was incredibly gifted as a medical illustrator. All before college. All before his accident. And all before golf. So it’s no surprise that for Rod and I growing up, Ed was a quintessential big brother. And after his accident he only became more so. He never second guessed the hand he was dealt, never felt sorry, never elicited or wanted anyone’s sympathy. And in all these years, if I ever had a setback or a loss, I could always put it in proper perspective just by having Ed as my brother. Family dinners after college and during holidays were not to be missed. Ed as a newly minted hospital administrator would engage our formidable father, who as dean of Northwestern University Medical School and who championed the academic and research side of medicine, would be engaged by Ed in discussions involving where health care was and where it should be headed.

Needless to say, and certainly to the merriment of his brothers around the table, Ed rarely prevailed in these discussions but he won our admiration and respect for tackling issues head on with our dad. Fast forward many years and after Ed and Judi started spending winters in Florida, Ed decided to hire his brother to design their house in Naples. Well, in the four years it took to design and build the house, I think it was the first and last decision Judi allowed Ed to make. Judi and I proceeded to work as a team to design the house to fit Ed like a glove to minimize his steps and maximize his efficiency of movement. But Ed resisted the very notion that the house should make it easy for him, just like he resisted using a WC (wheelchair?). If the house was going to be expensive and beautiful, then, damn it, he was going to take the extra steps to appreciate it. And despite the architect blowing the budget, Ed loved it. As brothers, we kidded Ed about not reading more books – or even reading at all – and he loved to say how he had read every book lining the walls of his elevator that got him to the second floor in the Naples house. It’s true, all the walls of the elevator were lined with books, but not one had any pages in them. But he got back at us by being the only one to actually write a book. Ed didn’t have to spend his life reading; he spent his life living. He spent his life inspiring others and spreading his incredible sense of humor. I have never laughed so much in my life as I did in the times I was with him. Ed had a secret, of course. His secret life was Judi. She allowed him to be who he was and despite all of the kidding, he always knew how lucky he was. Just as we all know how lucky we are to have had him in our lives.

Legislative Update

Congressional Activity Resumes in the Senate While Members of Congress traditionally enjoy the month of August away from Washington to spend time in their districts and states, this August unfolded a bit differently. The House of Representatives was out for the full month, but in June, Senate Majority Leader Mitch McConnell (RKY) announced that he was canceling all but one week of the August recess.

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

Highlights: »»

While House members maintained their traditional August recess, Senators returned to the Capitol after a week-long break to consider appropriations measures and nominations.

»»

Since the House departed for the August recess, Congress only has 11 legislative days remaining until federal funding runs out on September 30, 2018.

»»

Before November, Congress must reauthorize multiple major government programs, finalize Fiscal Year (FY) 2019 spending, and confirm presidential nominations, including a Supreme Court justice.

»»

CMS has begun its process of finalizing annual payment rules, including the release of the FY 2019 Inpatient Rehabilitation Facility Proposed Payment System (IRF PPS) Final Rule, the Skilled Nursing Facilities Prospective Payment System (SNF PPS) Final Rule, and the Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Prospective Payment System Final Rule.

»»

CMS announced it will allow Medicare Advantage plans the option of applying step therapy for physician-administered and other Part B drugs, among other policies focused on reducing the costs of prescription drugs.

»»

CMS released a proposed rule that would make changes to the Medicare Shared Savings Program to encourage Accountable Care Organizations (ACOs) to take on more risk by transitioning to two-sided models.

Leader McConnell is using the typically quiet month of August to address a host of outstanding issues before the Senate. The Senate approved a package of spending bills—a “minibus”—for Energy-Water, Legislative Branch, and Military ConstructionVeterans Affairs, sending the appropriations measures to a Conference Committee with the House. Further, the Senate disposed of a second minibus, this one containing appropriations for Interior, Financial Services, Agriculture, and Transportation-Housing and Urban Development. Later in August, the Senate plans to take up a third minibus package containing appropriations for Defense and Labor-Health and Human Services, which is expected to pass, provided it does not contain some of the “poison pill” riders in the House package. The relative ease with which the minibus packages have passed in the Senate is a credit to the bipartisan agreement by Appropriations Chair Richard Shelby (R-AL) and Ranking Member Patrick Leahy (D-VT) to avoid contentious policy riders being attached to spending measures. This has allowed the Senate to pass seven of the 12 annual appropriations bills with little challenge, a rare feat based on past years of partisan conflicts. Beyond appropriations, the Senate has quite a few other items that it may address during August, but will likely be considered once the House returns in early September. Senators could take action on the Water Resources Development Act reauthorization and/or possibly a package of opioid bills. The Senate also named its Conferees to the Farm Bill conference, so work on the final version of the Farm Bill will also be a priority. In addition to the busy legislative agenda, the Senate will also continue to consider executive and judicial nominations. Chief among these will be the marquee judicial confirmation battle over Judge Brett Kavanaugh to serve as an Associate Justice on the Supreme Court. Nominated by President Trump on July 9, Judge Kavanaugh currently serves on the D.C. Circuit of Appeals. The timing around Judge Kavanaugh’s confirmation hearing remains in flux, but Senate Judiciary Chair Chuck Grassley announced on August 1 that the hearings are likely to begin in September, with a final vote on confirmation coming in October. The flurry of activity in the Senate stands in stark contrast to the lack of legislative action that traditionally defines the late summer and fall of an election year. For the Senate, the uptick in activity shows a concerted, cross-party effort to legislate during

AMRPA Magazine / August 2018

the coming months and pass bipartisan measures in concert with the House. President Trump has made shutdown threats over immigration issues, including funding for a border wall that could come to a head over the eventual consideration of the Homeland Security funding bill. In addition, House Conservatives may block consideration of a Defense and Labor-HHS package in order to have greater influence on policy riders during the Lame Duck session. As we go to press, there is a rumor that Leader McConnell will “give back” the week before Labor Day to members so they may return to their home states. CMS Releases Final Payment Rules for IRFs, SNFs, and Inpatient PPS On July 31, the Centers for Medicare and Medicaid Services (CMS) issued the FY 2019 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Final Rule. The Final Rule moves forward with finalizing the removal of the FIM™ Instrument and associated Function Modifiers from the IRFPatient Assessment Instrument (PAI) for discharges beginning on or after October 1, 2019. CMS did not accept the AMRPA recommendation for delay. Further, CMS confirmed that the agency we will use two full years of data (FY 2017 and FY 2018) in its analyses used to revise the Case-Mix Group definitions, which will be effective beginning in FY 2020. In future rulemaking CMS will address changes to the revised Case-Mix Group definitions due to the incorporation of an additional year of data (FY 2018) into its analysis.

considered less financially risk-based models, and offers a basic and enhanced track. The basic track would allow eligible ACOs to begin under a one-sided model and incrementally phasein higher levels of risk that, at the highest level, would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program. The enhanced track, similar to the program’s existing Track 3, is a two-sided model that CMS has found to show significant savings to the Medicare program and quality improvement. CMS is providing the enhanced track with additional tools and flexibility for ACOs that take on the highest level of risk and potential reward. CMS estimates that this proposal will lead to 109 ACOs leaving the program within 10 years. This proposal builds on Health and Human Services (HHS) Secretary Azar’s comments earlier in the year that question whether ACOs were taking on enough financial risk and therefore saving the Medicare program money. Administration Takes Further Steps on Drug Pricing Following up on the release of the president’s drug-pricing blueprint in May, the Trump administration in recent weeks has taken a number of actions to address high prescription drug prices. President Trump himself called out several pharmaceutical manufacturers by name on Twitter, criticizing them for recent drug price increases. He later thanked some of them after the companies decided to postpone scheduled price hikes. HHS Secretary Alex Azar has also weighed in, praising one company’s decision to reduce prices on some of its products.

Of interest to AMRPA members, the SNF PPS Final Rule includes a new classification system, the Patient Driven Payment Model (PDPM), which aims to link skilled nursing facility payments to patients’ conditions and care needs rather than volume of services provided. CMS estimates that the transition to this model will save providers an estimated $2 billion over the next decade. CMS also finalized a 25 percent limit on group and concurrent therapy, which the agency argues will ensure at least 75 percent of a resident’s therapy minutes are provided on an individual basis.

On July 19, the Food and Drug Administration (FDA) announced that it would be forming a working group to explore the possibility of drug importation when a sole-source, off-patent drug experiences a significant price increase. While FDA emphasized that such importation would be limited and temporary, the announcement was surprising, given Secretary Azar’s previous criticism of importation proposals. FDA also released a Biosimilar Action Plan, expanding on initiatives to promote biosimilar development and competition. In remarks on the plan, FDA Commissioner Scott Gottlieb criticized “rebating schemes or patent thickets that are purely designed to deter the entry of biosimilars.”

Among other provisions in the Inpatient Prospective Payment System (IPPS) Rule, CMS finalized a proposal to allow IPPSexcluded hospitals to operate IPPS-excluded units, despite AMRPA’s objections. Therefore, beginning on October 1, 2019, IPPS-excluded hospitals (IRFs, LTCHs and psychiatric) will be allowed to operate IPPS-excluded units (IRF and psychiatric). CMS explains that the reason why it prohibited IPPS-excluded hospitals from operating IPPS-excluded units was because CMS was concerned that the IPPS-excluded hospital could artificially manipulate its TEFRA ceiling. CMS stated that concern is no longer valid, given reforms in payment systems for IPPS-excluded hospitals.

CMS is also taking steps on drug pricing, issuing a July 24 memo to Medicare Part D plans outlining ways they can encourage utilization of low-cost generics. In its calendar year 2019 Physician Fee Schedule Proposed Rule released on July 12, the agency included a proposal that would change how Medicare pays for Part B drugs by reducing the wholesale acquisition cost add-on payment from six percent to three percent, effective January 1, 2019. The Trump administration opined that this policy, which would pay physicians 3 percent less to administer new drugs, would curb high drug-spending while aligning payments and drug acquisition costs, particularly for drugs entering the marketplace with high launch prices.

CMS Proposes Stricter Rules for ACO Models On August 9, CMS released a proposed rule that would make changes to the Medicare Shared Savings Program and require that new Accountable Care Organizations (ACOs) transition to two-sided models within two years in order to begin sharing in both savings and losses. The proposal retires two of the models

On August 7, CMS announced it will permit Medicare Advantage (MA) plans the option of applying step therapy for physicianadministered and other Part B drugs beginning January 1, 2019. A common practice in commercial plans, CMS does include patient protections. The beneficiary can, of course, choose to not participate in an MA plan with the step therapy

AMRPA Magazine / August 2018

policy. Additionally, a beneficiary can submit a request for an exception if they need a specific drug that would otherwise only be available after trying a different drug. Additionally, step therapy can only be applied to new prescriptions of Part B drugs for beneficiaries that are not actively receiving the affected medication, meaning that no beneficiary currently receiving drugs under Part B will be forced to change their medication. MA plans must also offer drug management care coordination services and rewards that incentivize beneficiary participation, such as passing on savings directly in the form of gift cards. Finally, the Office of Management and Budget is now reviewing an HHS Office of Inspector General proposed rule that would both eliminate and create new safe harbor protections related to drug rebates for pharmacy benefit managers. Commissioner Gottlieb and Secretary Azar have both discussed the possibility of re-examining the safe harbors for drug rebates. More agency action should be anticipated this year as the administration endeavors to demonstrate its commitment to advancing the presidentâ&#x20AC;&#x2122;s blueprint. FCC Notice on Telehealth Pilot Program On August 2, the Federal Communications Commission (FCC) announced that it is seeking comments on the establishment of a $100 million Connected Care Pilot Program to promote the use of broadband-enabled telehealth among low-income

consumers. Specifically, FCC is interested in services delivered directly to patients â&#x20AC;&#x153;beyond the doors of brick-and-mortar health care facilities.â&#x20AC;? FCC is requesting comments on the following items: The goals of, and statutory authority for, the pilot program; the design of the pilot program, including the budget; the application process and types of telehealth pilot projects that should be funded; eligibility criteria for participating health care providers, broadband service providers, and low-income consumers; the broadband services and other communications services and equipment that should be supported; the amount of support and how it should be disbursed; and the duration of the program; and how to measure the effectiveness of pilot projects in achieving the goals of the program. Comments are due September 10, 2018. In closing, this is the month to continue your outreach to your Senate and House elected officials. With the election date looming, members often seize opportunities to visit hospitals and see patients. This time of year offers an excellent moment of opportunity and we urge you to seize it. The AMRPA team stands ready to assist you in any way. Thank you for all you are doing. Martha M. Kendrick Partner Akin Gump Strauss Hauer & Feld LLP

AMRPA Magazine / August 2018

Trump Administration Reshapes Private Insurance through Association Health Plans and ShortTerm Plans

Peter W. Thomas, Counsel to AMRPA’s Denials Management Committee, and Christina Hughes, Counsel, the Powers Law Firm

In the aftermath of Congress’s inability to pass a comprehensive bill to repeal and replace the Affordable Care Act (ACA), the Trump administration has turned to the regulatory process to leave its mark on the health insurance marketplace. Specifically, the administration has used regulations to expand the availability of plans that are exempt from the ACA’s essential health benefits (EHB) package and other consumer protections: association health plans (AHPs) and short-term limited duration plans (otherwise known as short-term plans or STLDs). Under these rules and others, the administration seeks to shift regulation of the health insurance marketplace to the states without many federal protections established under the ACA. The administration acknowledges that these regulations may adversely impact the risk pools for individual health insurance coverage and raise premiums for ACA-compliant plans. These same issues were raised by many commenters during the rulemaking process, along with the concern that individuals enrolled in short-term plans and AHPs may find themselves without the coverage they need after a sudden illness or injury. Despite these concerns, the administration believes that such regulations are necessary to increase consumer choice and lower health care costs. Department of Labor Expands Availability of AHPs On June 21, the Employee Benefits Security administration at the Department of Labor (DOL) published its final rule expanding the availability of AHPs.1 This rule finalizes changes that allow more small businesses, as well as self-employed individuals, to band together for the purpose of purchasing health care plans that do not have to comply with the rules of the individual and small group markets under the ACA. The final rule went into effect on August 20, 2018. In the Final Rule, DOL expanded the pool of individuals and businesses that can organize to purchase AHPs. Under these changes, self-employed individuals can act as employers for purposes of joining an AHP while acting as employees in order to be covered by the AHP. This is a significant change from prior advisory opinions and guidance issued by DOL. In addition, while groups of employers must still have a business purpose unrelated to the provision of benefits to be eligible to sponsor an AHP, these employers are not required to operate in the same industry or profession. Instead, employers who are located within the same state or metropolitan area can form these groups to provide AHPs. 1. Definition of “Employer” Under Section 3(5) of ERISA—Association Health Plans, 83 Fed. Reg. 28,912 (June 21, 2018).

10 AMRPA Magazine / August 2018

As AHPs do not have to comply with the rules of the individual and small group markets under the ACA, AHPs are not required to provide the full EHB package, including rehabilitative and habilitative services and devices, prescription drugs, mental or behavioral health, or chronic disease management. While AHPs are not required to cover EHBs, DOL did clarify in its final rule that to the extent a plan does cover benefits that would be considered an EHB, all such benefits must be covered without any annual or lifetime dollar limits. AHPs cannot discriminate in eligibility, benefits or premiums against an individual within a group of similarly situated individuals (such as employees of the same company) based on a health factor, including disability. AHPs may make distinctions, however, between groups of individuals based on “bona fide employment-based classifications,” such as full-time versus part-time employment, date of hire, or occupation, so long as such distinction is not directed at individual participants or beneficiaries based on a health factor. In response to comments requesting stronger nondiscrimination provisions for AHPs, DOL declined to implement additional protections, but clarified that AHPs’ ability to discriminate based on non-health factors is subject to state regulation. Agencies Extend Duration of Short-Term Plans On August 3, the Department of Treasury, the Department of Labor and the Department of Health and Human Services (collectively, “the Agencies”) published a final rule on short-term plans.2 The rule changes the definition of short-term plans to allow for the issuance of plans that provide coverage for up to 12 months, with the potential to renew for up to 36 months. The previous maximum for short-term plans under the ACA was three months and they could not be renewed. Short-term plans are not required to comply with the ACA’s EHB requirements, rules about annual or lifetime caps, protections for individuals with preexisting conditions, and other consumer protections. The final rule goes into effect on October 2, 2018. During the rulemaking process, many stakeholders expressed concern that these plans will be able to mimic or be inaccurately marketed as “major medical coverage” that lasts for a full year, and therefore consumers may be unaware that they are enrolling in a less comprehensive policy. The Agencies believe that the notice requirement in the final rule addresses these concerns. Issuers of short-term plans must display a notice prominently in the contract and any application materials that states that the plan does not qualify as “major medical coverage” and that the plan may not have the same consumer protections or cover the same benefits as required by the ACA. The Agencies also confirmed that states are free to adopt a definition of shortterm plans with a shorter maximum length or require additional information be included in the consumer notice. Stakeholders also warned that short-term plans may fail to cover a full range of benefits and may discriminate against individuals with greater health care needs through benefit plan design. The Agencies declined to adopt any additional federal standards for

// Proponents of these rules believe that greater availability of AHPs and short term plans will make it easier and less costly for certain individuals to obtain private insurance, thereby expanding insurance options and providing less expensive private coverage. short-term plans; however, the Agencies emphasized that states generally remain free to apply EHB requirements and consumer protection standards to short-term plans as they see fit. The Agencies further clarified that the regulation establishes federal rules for short-term plans only with respect to the maximum length of the initial contract term, the maximum duration of a policy, and a consumer notice. The Agencies explicitly stated that states are free to regulate such coverage in every other respect, including by prohibiting the sale of short-term plans. Impact on the Insurance Marketplace and State Regulation These regulations, along with the 2019 Notice of Benefit and Payment Parameters final rule,3 are a part of the administration’s effort to reduce regulatory constraints on states and insurers, including by removing certain consumer protections and coverage of EHBs. This trend is being pursued with the goal of expanding more affordable plan options for consumers, but many fear it will trim critical benefits and limit choices for those with greater-than-average health care needs, such as people with disabilities and chronic conditions. Proponents of these rules believe that greater availability of AHPs and short term plans will make it easier and less costly for certain individuals to obtain private insurance, thereby expanding insurance options and providing less expensive private coverage. Critics believe these rules encourage younger and healthier enrollees to exit the ACA marketplaces and obtain insurance that skirts ACA nondiscrimination and EHB requirements. The net impact on the marketplaces is a more expensive risk pool and rising insurance rates for ACA-compliant plans. Similarly, the proliferation of ACA-exempt plans that offer less coverage may surprise some consumers after an illness or injury when they need coverage the most. In the proposed and final rules for these regulations, the Agencies themselves recognized that making AHPs and short-term plans more available could have an impact on the risk pools for individual health insurance coverage and raise premiums for such coverage. The Agencies stated, however,

2. Short-Term, Limited-Duration Insurance, 83 Fed. Reg. 38,212 (Aug. 3, 2018). 3. Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2019, 83 Fed. Reg. 16,930 (Apr. 17, 2018).

AMRPA Magazine / August 2018 11

that they â&#x20AC;&#x153;believe the critical need for coverage options that are more affordable than individual health insurance coverage, combined with the general need for more coverage options and choice, substantially outweigh the estimated impact on individual health insurance premiums.â&#x20AC;? Under these regulations, AHPs and short-term plans would still be subject to state benefit mandates and consumer protection requirements, as well as a number of other state insurance regulations mentioned above. In conjunction with the 2019 Notice of Benefit and Payment Parameters final rule, this is part of a larger trend in this administration to shift regulatory authority over the health insurance marketplace to state governments. Conclusion The Trump administration is expected to continue to employ the regulatory process to make its mark on the health insurance

marketplace, absent Congressional action in this area. While the administration states that these regulatory changes are being made in the name of expanding affordable plan options for consumers, these regulations will likely trim critical benefits, including rehabilitative and habilitative services and devices, and potentially limit choices for individuals with disabilities, chronic conditions and anyone with greater-than-average health care needs. Many individuals may also be left without critical benefit coverage at the times that they need it most. Finally, these regulations allow states greater flexibility to pursue their own path by shifting decision-making authority to the states. Written by Peter W. Thomas, Counsel, AMRPA Consumer and Clinical Affairs Committee and Denials Management Task Force, and Christina Krysinski, Associate, Powers Pyles Sutter & Verville, PC.

MARKET YOUR PRODUCTS & SERVICES TO THE RIGHT AUDIENCE 57% of conference attendees are the decision makers when it comes to purchases within their organization. Tiered sponsorship packages available!

Visit www.amrpa.org to view the sponsorship and exhibitor prospectus and get involved today.

12 AMRPA Magazine / August 2018

Key Developments in Medicare Audits and Appeals

Set forth below is a synopsis of key developments involving Medicare audits and appeals for the inpatient rehabilitation hospital and unit (IRH/U) community.

Peter W. Thomas, Counsel to AMRPA’s Denials Management Committee, and Christina Hughes, Counsel, the Powers Law Firm

RAC Audits on the Horizon Again On August 7, 2018, the Centers for Medicare and Medicaid Services (CMS) posted a new proposed issue for Recovery Auditor Contractor (RAC) review that would permit audits of IRH/U admissions. The posted description states: “Inpatient hospital services furnished to a patient in a[n] inpatient rehabilitation facility will be reviewed to determine that services were medically reasonable and necessary.” If approved, the issue would be eligible for review in all four RAC jurisdictions. No other limitations or caveats are included in the proposed issue. At this time, the issue is only proposed for review. Last year, review of IRH/U admissions was also proposed, but it was never approved for review and eventually disappeared from the proposed issues list. CMS accepts comments and questions on proposed issues for 30 days following the initial posting. After the 30-day period has passed, CMS has discretion to approve the topics for review by the RACs, or not. If the issue is approved for review, each RAC must individually post the issue as an approved issue on its website and the posting must be active for at least two weeks prior to the RAC sending any Additional Documentation Requests (ADRs). If ADRs are sent, the RACs are subject to strict limits on the number of records that may be requested. An annual baseline ADR limit is set for each provider based on the individual CMS Certification Number (CCN) and National Provider Identifier (NPI) associated with that provider. The baseline limit is set at one-half of one percent (0.5 percent) of the total paid Medicare claims in the previous 12-month period. The annual baseline ADR limit is divided by eight to determine how many ADRs a RAC may issue for a provider in a single 45-day period. For providers that incorporate a rehabilitation unit along with other care settings under a single CCN/NPI set, the number of paid claims and the resulting ADR limit will almost certainly be higher than for a freestanding IRH/U. However, if the provider submits more than one claim type (on different Types of Bills (TOBs)), the ADRs cannot be concentrated on a single claim type. After three 45-day ADR cycles, the RAC is permitted to create a risk-based adjusted ADR limit, based on the provider’s denial rate established in the preceding ADR cycles.

AMRPA Magazine / August 2018 13

The higher the denial rate, the higher percentage of annual Medicare paid claims the RAC is permitted to use as the ADR limit—for any denial rate greater than 50 percent, the percentage ranges from 3 percent to 5 percent. For providers with a denial rate of 20 percent or less, the percentage remains at 0.5 percent or lower. And for those providers with a denial rate of 3 percent or less, the provider is immunized from further ADRs for at least three 45-day cycles. The lookback period for the RACs depends on whether they opt to use the baseline ADR limit or calculate an adjusted ADR limit. For the baseline ADR limit, RACs are permitted to lookback three years, based on the date of final determination (i.e., payment of the claim). If a RAC chooses to use the risk-based adjusted ADR limit, the lookback period is significantly shorter—only six months. This is supposed to create an audit environment where a provider is only being penalized (through the imposition of additional audits) for their relatively current performance. Given that CMS previously proposed IRH/U claims for RAC review last year, it seems highly probable that the issue will be approved for RAC review this year. However, it remains unclear what caused the issue to be dropped, without comment or note, from consideration last year. One factor that may be playing into last year’s abandonment of the topic and its re-emergence this year is the conclusion of the recent round of audits by the Supplemental Medical Review Contractor (SMRC). It is unclear whether the newly transitioned SMRC will be tasked with continuing to audit IRH/U claims as well. In any event, it unfortunately appears as though IRH/Us should prepare themselves for continued Medicare audits for the foreseeable future. Status Update on the ALJ Backlog On August 3, 2018, the Department of Health and Human Services (HHS) submitted its most recent filing to the court in the American Hospital Association’s suit challenging the backlog in administrative law judge (ALJ) hearings and decisions, AHA v. Azar. The status report indicated that the Office of Medicare Hearings and Appeals (OMHA) had received a huge infusion of funding from Congress, which in turn allows OMHA to hire additional ALJ teams. Specifically, HHS cited an additional 80 ALJ teams to be added over the next 14 months, approximately doubling OMHA’s capacity to decide cases. With a newly estimated capacity for 180,000 decisions per year, HHS now estimates that the backlog (including any appeals filed in the interim) will be cleared by sometime in fiscal year (FY) 2022. At the beginning of FY 2018, OMHA had 578,683 pending appeals, and was projected to receive an additional 71,634 in new hearing requests. Based on estimates of similar new receipts over the coming years (ranging from 74,572 in FY 2019 to 86,150 in FY 2022), HHS projects a steadily declining number of backlogged appeals. It should be noted that HHS’ projections may be overly

14 AMRPA Magazine / August 2018

// Despite the possibly overly optimistic projections from HHS, AHA seized on the status report as evidence that OMHA could indeed clear the backlog of appeals within a proscribed timeframe and requested that the court reimpose deadlines for handling the pending appeals. optimistic—in FY 2017, OMHA received 112,933 new hearing requests and CMS has now launched the Targeted Probe & Educate (TPE) audit program and continues to propose and approve new issues for RAC review. The government’s ALJ backlog projections also rely on a certain number of “Administrative Actions,” which include settlements of claims through the Settlement Conference Facilitation (SCF) program, the Low-Volume Appellants (LVA) program, and any other settlements undertaken by CMS or HHS. The LVA program—at 62 percent—has resulted in the settlement of only 13,000 claims, so it has not been the success OMHA had hoped. In contrast, the SCF has resulted in the settlement of approximately 72,000 claims, and the program was recently expanded to cover more appellants. Finally, as noted in its status report, CMS and IRH/U stakeholders continue discussions about a potential global settlement for IRH/U appeals—approximately 12,000 appeals in total. (This number of appeals had previously been estimated by CMS to be as high as 15,700 appeals.) Despite the possibly overly optimistic projections from HHS, AHA seized on the status report as evidence that OMHA could indeed clear the backlog of appeals within a proscribed timeframe and requested that the court re-impose deadlines for handling the pending appeals. This is especially important in light of HHS’ rejection of all the non-deadline-based alternatives previously proposed by AHA (e.g., RAC reform, lowering the interest rate, permitting rebilling, tolling the deadline for appealing certain claims). Now it is a question of waiting to see what the court will do with the new information provided by HHS.

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

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

AMRPA Magazine / August 2018 15

Common FIM Scoring Errors

Last month I reviewed what I consider to be essentials related to the capture of burden of care as it pertains to functional independence measures (FIM). This month I am extending that topic to common FIM scoring and documentation inconsistencies. The following 10 examples cover issues I have found while auditing charts. I hope you can learn from these topics and include them in your own record reviews.

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

1. Patient had a score of “4” for bed transfers and toilet transfers per the FIM sheet, but the nursing narrative notes said the patient was moderate assistance with all transfers. Scoring a “3” for bed and toilet transfers in this case resulted in a CMG assignment change from D2001 to D2002. Lesson: When completing the IRF-PAI, review all documentation in the chart for the first 3 days of the stay to ensure that all the evidence for burden of care is considered. In this case, additional documentation indicating which element of the transfer required moderate assistance would have been helpful. 2. Patient was able to walk 150 feet on the day of evaluation, but the PT advanced his assistive device on day three and the patient was only able to walk 45 feet before he needed a standing rest break. The IRF-PAI was scored with a “3,” but, per the PT notes indicating the distance walked on day three before the patient needed a break, the score should have been “1”. Scoring “1” would have resulted in CMG A2003 rather than CMG A2002. Lesson: Make sure that all therapy documentation for the evaluation and subsequent treatments are reviewed when choosing FIM scores for the IRFPAI. Remember that standing rest breaks also count as the end of the distance traveled for the FIM scoring episode. 3. Patient had a lower body dressing score of “3” per the nursing and OT FIM’s until day three, when the patient required maximal assistance with the task. Scoring a “2” would have resulted in CMG D1503 rather than D1502. Lesson: Just as noted above, all therapy documentation should be reviewed and considered when selecting the correct FIM scores for the IRF-PAI. Furthermore, therapists and nurses should be reminded to add scores to the FIM sheet on a daily basis. 4. Patient had a toilet transfer score of “4” on day three, but a “0” was recorded on the IRF-PAI. Since the activity occurred within the first three days of the stay, the accurate score is actually “4”. This change would assign the correct CMG of A0301 rather than A0302. Lesson: A score of “0” should never be used when the documentation contains evidence that the activity occurred in the first three days of the patient’s stay.

16 AMRPA Magazine / August 2018

5. Patient had three bladder accidents in the last four days of his acute care stay as per the pre-admission screening (PAS). The bladder score on the IRF-PAI was “4”, but it should have been “3” based on the information in the PAS. This would have resulted in a CMG of A0105 instead of A0104. Lesson: Review the PAS for documentation of bladder and bowel accidents when determining the final IRF-PAI score for these two items. 6. Patient wore Depends at night and required total assistance to change it. The night nurse did not record a score for bladder or bowel during her shift. The IRF-PAI scores for bladder and bowel level of assistance were “5”, which was consistent with day-shift nursing scores. Since the narrative notes clearly captured total assistance at night, the correct scores for bladder and bowel level of assistance would be “1”, which would have resulted in CMG A0503 rather than A0502. Lesson: Reinforce the importance of having all staff record scores on the FIM sheet during every shift. 7. Patient had mode of locomotion upon discharge marked as “both,” so the IRF-PAI score should be the lower of walk and wheelchair. The patient’s walk score was used, but the lower of the scores was wheelchair. The score of “1” for wheelchair would have resulted in CMG A0604 rather than A0603. Lesson: Ensure that physical therapists indicate the most frequent mode of locomotion projected upon discharge. Use that score as the IRF-PAI score. When “both” is marked, then use the lower of the walk or wheelchair scores. 8. Patient had a bathing score of “0” but a tub transfer score of “3”. There was no evidence in the documentation to reflect a wet, naked shower; therefore, the score of “3” was likely a simulation of the transfer. The correct IRF-PAI score would have been “0” for tub transfer. This would not have resulted in a change in the CMG. Lesson: Do not record scores on the IRF-PAI if the actual task did not occur. Simulations may be done for goal setting and planning, but the results should not be recorded on the IRF-PAI. 9. Patient had limited therapy over the weekend and was transferred to acute care on Monday. His IRF-PAI discharge scores were pulled from the therapy discharge summaries that indicated the patient was moderate-assistance with all tasks. There was no documentation to support that level of function, however, since the therapists did not see him for full sessions over the weekend. The nursing documentation addressed some of the ADL items and transfers, but they did not record walk or stairs scores, nor did they complete a full shower transfer. These scores should have been recorded as “0” for walk, and “1” for stairs and shower transfer. The other items should be scored according to the nursing documentation. This would not have resulted in a change in the CMG. Lesson: Pull discharge scores according to the rules stated in the IRF-PAI Training Manual, Section III, page 3, which states that the lowest score should be pulled from a 24-hour period selected from the last three days of the stay. Remember that the activity must be performed for a score to be recorded. Clinical judgement cannot be used to project what the score might be.

// The best practice when you find errors is to share your findings with staff on a regular basis, if not as soon as you find them, so your staff remembers the importance of consistency of documentation and recording accurate scores in a timely manner. 10. The bowel score recorded on the nursing FIM sheet was “3” the two days prior to discharge, “4” the day prior to discharge, and “5” on the day of discharge. The patient had no accidents during his stay. Because the 24-hour period selected for recording discharge scores was the day before discharge, the bowel score recorded on the IRF-PAI was recorded as “4”. The correct score was “3”, however, since the bowel and bladder level of assistance discharge look back period is three days and the frequency of accidents look back period is seven days. This would not have resulted in a CMG change. Lesson: Remember that the bladder and bowel level of assistance look back period is three days for both admission and discharge. The frequency of accidents look back period is seven days for both admission and discharge. As I have said many times before, it is important to review all of the documentation in the chart for the first three days of the stay when recording FIM scores on the IRF-PAI. I hope these examples prove my point. It is costly to rely on nurses and therapists to record everything on the FIM sheet accurately every time if they are doing so from memory. You will find discrepancies just like these examples. The best practice when you find errors is to share your findings with staff on a regular basis, if not as soon as you find them, so your staff remembers the importance of consistency of documentation and recording accurate scores in a timely manner. Ask questions of your staff when things are unclear to help teach them how to document more comprehensibly the next time. Please understand that these examples do not include the volume of information that I had to draw from when reviewing the actual records, so if you believe there may be some theoretical circumstances that would support the original coding, you are probably correct. Every patient presents differently. Concentrate on the big-picture lessons each example represents.

AMRPA Magazine / August 2018 17

CMS Issues FY 2019 IRF PPS Final Rule: Adopts Proposals to Move to New CMGs, Adds an Additional Year of Data Analysis and Eliminates the FIM™ On July 31, the Centers for Medicare and Medicaid Services (CMS) announced the federal fiscal year (FY) 2019 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) final rule. CMS published a Fact Sheet highlighting major provisions of the rule, which was published in the August 6, 2018, edition of the Federal Register.

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

Mimi Zhang, Senior Policy and Research Analyst

18 AMRPA Magazine / August 2018

As noted at the time of the proposed rule, the administration has repeatedly stated how it seeks to reduce the regulatory burden imposed by regulations and statutes on business and the public. At CMS, these directives have been borne out through the agency’s Patients Over Paperwork initiative, which seeks to evaluate and streamline regulations with a goal to reduce unnecessary burden, increase efficiencies, and to improve the beneficiary experience and other efforts including most recently this rule and others for either FY 2019 or calendar year (CY) 2019. For example, in the FY 2018 IRF PPS proposed rule, CMS included a Request for Information (RFI) on “CMS Flexibilities and Efficiencies” inviting ideas for changes with respect to regulatory, sub-regulatory, policy, practice and procedures changes – the whole gamut of how the government issues its policies and practices. AMRPA responded with an extensive series of recommendations. In issuing the FY 2019 IRF PPS proposed rule, CMS stated it was revising the Case Mix Groups (CMGs) and eliminating the Functional Independence Measures (FIM™) as part of its initiative to reduce regulatory burden. Even given that optimistic showcasing, stakeholders did not find it palatable. Hence, AMRPA was disappointed to see that CMS adopted its proposals to institute new CMGs based on functional status data from the Quality Indicators section of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) and remove the Functional Independence Measures (FIM™) instrument from the IRF-PAI effective October 1, 2019 (FY 2020). The Quality Indicator data items being used are captured in Sections GG, H, C and B of the IRF-PAI and are collected pursuant to the Improving Medicare Post-Acute Transformation (IMPACT) Act. However, recognizing AMRPA and others’ advocacy on this issue, CMS will now use two years of data (FYs 2017-2018) in

its analysis to develop the FY 2020 CMGs instead of using solely FY 2017 data. CMS will use the new IRF-PAI version 3.0 which is effective October 1, 2019. We urge all members to start to become familiar with it now. Over the past several years CMS has been extensively revising all post-acute care (PAC) providers’ payment systems. The final changes for the Skilled Nursing Facility Prospective Payment System (SNF PPS) were also announced on July 31. Among other changes, it revised the SNF case-mix classification system to now be called the Patient- Driven Payment Model (PDPM), also effective in FY 2020 (October 1, 2019), which ties SNF payments to patient characteristics rather than the amount of therapy delivered. On July 2, CMS issued the proposed rule for the Home Health Prospective Payment System (HH PPS) for CY 2019, which included extensive changes to the HH PPS case-mix classification system that will be called the Patient-Driven Grouping Model (PDGM), and utilize a the unit of payment from 60 days to 30 days, among other changes, to be effective in 2020. Extensive changes to the Long-term Care Hospital Prospective Payment System (LTCH PPS) were made by statute several years ago pursuant to the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013. Hence, if the HH PPS proposals are finalized, all PAC providers will be operating on new classification and payment systems by FY 2020. Other notable changes in this IRF final rule are changes to the IRF coverage requirements. CMS will now allow physicians to attend the weekly team meetings remotely and will allow for the postadmission physician evaluation to count towards one of the three required weekly face-to-face physician visits. For the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP), CMS will remove two measures from the IRF QRP measure set which AMRPA supported, publicly report four functional outcomes measures in 2020, and adopt a new measure removal factor in accordance with the agency’s Meaningful Measures objectives. CMS finalized most of its payment proposals for FY 2019. However, it made small adjustments to the originally proposed outlier threshold and labor-related share due to more recent data that became available since the proposed rule. For the FY 2019 changes, CMS estimates that there will be a $105 million increase in IRF PPS payments, which is a net revenue increase of approximately 1.3 percent. The agency also estimates that there will be a $23 million reduction in costs in FY 2019 for IRFs due to changing coverage and reporting requirements, and a $10.5 million reduction in costs in FY 2020 due to the removal of the FIMTM reporting requirements. A. Removal of the FIMTM Instrument and Revisions to the IRF PPS Case-Mix Groups Effective FY 2020 As noted, CMS finalized its proposal to remove the FIMTM instrument and associated Functional Modifiers from the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) effective for discharges beginning on or after October 1, 2019 (FY 2020). CMS states that because

// For the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP), CMS will remove two measures from the IRF QRP measure set which AMRPA supported, publicly report four functional outcomes measures in 2020, and adopt a new measure removal factor in accordance with the agency’s Meaningful Measures objectives. data elements collected in the FIMTM instrument “overlap, directly or indirectly,” with data items in the Quality Indicators section of the IRF-PAI, the agency can now use Quality Indicators data items for payment purposes, i.e., for assigning patients to CMGs. CMS further states that it is “no longer necessary” to collect FIMTM data and that the continued collection of FIMTM items in addition to reporting the Quality Indicators data places “undue burden” on IRFs. Therefore over the next year CMS will develop revised CMGs using two fiscal years (FYs 2017-2018) of functional assessment data collected from the Quality Indicators section of the IRF-PAI. CMS also asserts that transitioning to Quality Indicator items for payment would support its broader goal of using and collecting standardized patient assessment data across post-acute care settings. AMRPA strongly advocated for the agency to use multiple years’ worth of data. In recognition of AMRPA’s and other stakeholders’ comments, CMS did not finalize the revised CMG definitions it had previously proposed (see Table 9 in the final rule), as those were based on only one year of data. The FIMTM instrument and associated Function Modifiers are currently used to assign a patient into a CMG for payment purposes under the IRF PPS. Specifically, CMS will remove the following IRF PAI items: • Item 39, which contains 18 of the FIMTM data elements and the FIMTM scale used to assess both motor and cognitive functioning at admission and discharge. • Items 29-38, which contain Function Modifiers associated with the FIMTM instrument.

AMRPA Magazine / August 2018 19

Pursuant to the IRF QRP, more than 20 data items are collected as Quality Indicators via the IRF PAI on Sections B, C, GG, and H. CMS published IRF PAI version 3.0 effective October 1, 2019 (FY 2020). IRF PAI version 3.0, and a table indicating changes from IRF PAI 2.0, are available for download on the CMS website. The final rule does not include additional analytical reports or details beyond what was published with the FY 2019 IRF PPS proposed rule, Analyses to Inform the Potential Use of Standardized Patient Assessment Data Elements in the Inpatient Rehabilitation Facility Prospective Payment System by RTI International. CMS states that any changes to the revised CMG definitions (including relative weights and ALOS values) will be addressed in future rulemaking prior to implementation in FY 2020. Because the new CMGs are to be based on FYs 2017 and 2018 data, the final rule does not include analyses as to how the resulting FY 2020 CMGs, which will be implemented in a budget neutral manner. AMRPA urged CMS to ensure that providers are adequately educated and trained before using the Quality Indicator items for payment purposes. CMS stated that it plans to provide training and educational resources on the data items in the Quality Indicators section of the IRF-PAI before the new policies take effect on October 1, 2019. 1. Functional Status Scores As readers are aware, under the current IRF PPS case-mix classification system a patient is assigned into one of 92 CMGs based on the primary reason for rehabilitation care (diagnosis), age and functional status. The functional status component is comprised of a motor score (weighted) and cognitive score (unweighted). However, based on the analysis conducted by RTI International noted above, CMS will revise the case-mix classification system so that the functional status scores is composed of patient’s motor function, a memory function, a communication function (based on comprehension and expression), and age. In other words, the motor score, memory score, communication score and age will feed into the functional status score used to group patients into CMGs under the IRF PPS beginning in FY 2020. Specifically, CMS will derive various scores from the following Quality Indicator data items: • The motor items used to derive the additive motor score are: Eating, oral hygiene, toileting hygiene, shower bathe/self, upper body dressing, lower body dressing, putting on/taking off footwear, bladder continence, bowel continence, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/ bed-to-chair transfer, toilet transfer, walk 10 feet, walk 50 feet with two turns, walk 150 feet, and 1 step (curb). These items are collected in Sections GG and H of the IRF PAI.

20 AMRPA Magazine / August 2018

• The item used to derive the memory score is the BIMS summary score, which is based on the repetition of three words, temporal orientation and recall. This is collected in IRF PAI Section C. • The communication score is derived from the hearing, speech and vision items collected on IRF PAI Section B. The items assess patients’ expression of ideas and wants and understanding verbal and non-verbal content. Whether the additional year’s data will influence the use of the above items in developing the FY 2020 CMGs has of course yet to be seen. Although the IRF PPS case-mix system currently uses a weighted motor score, CMS is not using a weighted motor score for the FY 2020 CMGs, stating that its “analysis at this time does not identify any benefit from weighting the items in the motor score.” Additionally, CMS thinks that the “unweighted motor score facilitates greater understanding among the provider community, as it is less complex.” Table 9 in the rule was reprinted for the new proposed CMGs but these are not final as they may be revised due to CMS now analyzing two years of data. From its original analysis, CMS believes the following would be the most significant technical differences between the current CMGs and the proposed revised CMGs: • Four fewer CMGs (88 instead of 92 currently). • Fewer CMGs in RICs 1, 2, 5, 8, 11 and 19. • More CMGs in RICs 3, 4, 10, 13, 15, 17, and 18. • A patient’s age would affect assignment for CMGs in RICs 1, 3, 4, and 13 whereas it currently affects assignment for CMGs in RICs 1, 4, and 8. Note that CMS did not propose any changes to the methodology used to update the CMGs, relative weights and ALOS values for FY 2019 (effective for discharges occurring on or after October 1, 2018, and on or before September 30, 2019). In the final rule, CMS addressed several issues regarding how certain motor or cognitive data items from the Quality Indicators section would, or would not, be incorporated in the functional scores used for CMG purposes: • On the omission of cognitive scores in the revised CMG definitions: “We believe that the fact that patients’ cognitive scores do not show up as significant in the Classification and Regression Tree (CART) analysis in any other Rehabilitation Impairment Categories (RICs) may be due in large part to the limitations with the cognitive items that were proposed to be incorporated into the revised case-mix system. The cognitive items that we used for this analysis are the best ones that we have for use at the present time,

but we will certainly consider the incorporation of revised cognitive data items into the CMG definitions if and when they become available in the future. We also note that, while a cognitive score is not included in the revised CMG definitions, the motor score may capture aspects of cognitive status as the scale measures the need for assistance, including supervision.” Finding sensitive, valid and agreedupon cognitive items that correlate with resource use and payment seems to be an elusive task. • On the omission of wheelchair mobility assessment items from the motor subscore: “RTI’s analysis of the items ‘wheel 50 feet with two turns’ and ‘wheel 150 feet with two turns’ indicated that the majority of these items are currently coded as 1 (Dependent) or utilized an ‘activity was not attempted code.’ We do not believe that the omission of these items from the motor score would have any impact on wheelchair dependent patients. We thank the commenters for their suggestions and will consider the incorporation of the data items identified above into the motor score in the future.” • On the omission of the 12-steps mobility item (GG01O1) from the motor subscore: “RTI’s analysis of the variables that were most predictive of costs found a higher use of ‘activity not attempted codes’ for more challenging items such as GG017O1 and found that there was less variability overall in the score for these items across all patients on admission, which may be due to discretion in the assessment of these activities. Based on this finding, the more challenging items including stairs and car transfers were not included in the motor score.” 2. Score Recoding Methodology There are several key differences between the Quality Indicators rating system and the FIM™ rating system: • The data items from the Quality Indicators are generally assessed using a six-level rating scale for the self-care and mobility elements and a four-level scale for the cognitive elements. The FIM ™ data items use a seven-level scale. • The data items from the Quality Indicators are assessed based on a patient’s usual performance during the assessment period, whereas the FIMTM items are assessed based on the patients lowest functional score during the assessment period. • The FIM™ scale includes a value of zero to indicate an activity did not occur or was not observed. In contrast, the Quality Indicator data items use the following four codes to indicate why an activity did not occur: the patient refused to complete an activity (code 07), the patient did not perform this activity (code 09), the activity was not attempted due to environmental limitations (code 10), or the activity was not attempted due to a medical condition or safety concern (code 88).

CMS finalized its proposed revisions to the coding values used in the Quality Indicator data items, effective October 1, 2019. CMS believes these changes are necessary to reflect the new use of the Quality Indicator data items for payment purposes. For the self-care and mobility items, the values of 07, 09, 10, 88 and the presence of a dash (“-”) will be recoded to 1, the most dependent level, except the toilet transfer item, which is recoded to 2. The bowel and bladder continence values will be recoded as follows: • For the bladder continence item, CMS will reassign a value of 1 (stress incontinence only) to 0 (always continent), a value of 5 (no urine output) to 0 (always continent), and a value of 9 (not applicable) to 4 (always incontinent). • For the bowel continence item, CMS will reassign a value of 9 (not rated) to 2 (frequently incontinent). • For both items, CMS will reassign a missing score to 0 (always continent). CMS states that it does not believe that the score recoding methodology could have a significant operational impact on providers as it does not impact the data collection or submission process of IRF-PAI data. B. Changes to IRF PPS Coverage Requirements In the proposed rule, CMS stated that as part of its Patients Over Paperwork initiative and in an effort to reduce provider burden, it sought changes to several coverage requirements under the IRF PPS. CMS adopted several proposals consistent with AMRPA’s recommendations. However, CMS is also proceeding with its proposal to permit physicians to attend interdisciplinary team meetings remotely. 1. Post-Admission Physician Evaluation As AMRPA recommended, the agency adopted the proposal to allow the Post-Admission Physician Evaluation (PAPE) to count towards one of the required three weekly face-to-face physician visits during the first week of a patient’s stay in an IRF. CMS did not change any other requirements regarding the PAPE, including the requirement it be completed within 24 hours of admission. CMS estimated in the proposed rule that this change would save $40.5 million annually in Part B payments to physicians, or an average of approximately $36,000 annually per IRF, due to reduced physician visits. In response to stakeholder feedback that CMS was overestimating the number of patients that would actually receive a reduced number of visits, CMS revised its estimate downwards to only be a savings of $20.5 million annually. 2. Remote Physician Attendance at Interdisciplinary Team Meeting CMS finalized its proposal to permit the rehabilitation physician to lead the required interdisciplinary team meeting remotely without any additional documentation requirements. AMRPA expressed concern that this

AMRPA Magazine / August 2018 21

change would be a move towards less-patient centered care in the rehabilitation hospital. CMS responded that hospitals would still be able to set their own policies about remote attendance, and that this proposal would alleviate the documentation burden on physicians and allow the physicians “increased flexibility for time management.” 3. Admission Order Documentation Requirement CMS adopted its proposal to remove the requirement under the IRF PPS regulations that there be a physician order for inpatient care in the medical record. CMS believes this requirement is duplicative of the requirements under the Medicare Conditions of Participation (CoPs) regulations for hospitals as well as the requirements under the general Medicare Part A payment regulations that are applicable to IRFs. Therefore, even though this requirement is eliminated from the IRF Coverage Requirements, there will still need to be an admission order when a patient is admitted to an IRF since IRFs must adhere to all CoPs. AMRPA generally supported this removal, but also asked for clarification on whether this change would mean IRFs could no longer be denied payment due to a deficient admission order. CMS offered no clarification on that point in the final rule. 4. Seeking Information on Additional Changes to the Physician Supervision Requirements In addition to the above changes, CMS also sought comment on two areas it is considering for potential future changes. 1. Remote Physician Visits The first area is whether some of the three weekly required physician visits could be completed remotely. AMRPA provided a detailed response expressing reservations about remote physician visits and the ability of clinicians to properly assess and treat patients remotely. 2. Use of Non-Physician Practitioners The second area CMS requested information on was the use of non-physician practitioners, such as physician assistants, to satisfy some of the coverage criteria that must currently be completed only by a physician. In the proposed rule CMS stated it would like to explore this possible change, but it had questions about whether non-physician practitioners have the specialized training in rehabilitation that would enable them to adequately treat and assess patients, and whether patients will continue to receive the hospital-level and quality of care necessary to treat the complexity of patients found in IRH/Us. AMRPA also provided comments on this topic cautioning CMS against moving away from physician-led care. CMS did not provide a detailed response to comments, but, again, said it would consider these stakeholder comments for future rulemaking.

22 AMRPA Magazine / August 2018

C. Proposed Changes to IRF QRP 1. Removal of Two IRF QRP Measures CMS adopted its proposals to remove two measures from the IRF QRP measure set: • National Healthcare Safety Network (NHSN) Facilitywide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716). - Providers will no longer be required to submit data on this measure for the purposes of the IRF QRP beginning with October 1, 2018, admissions and discharges. • Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680). - Providers will no longer be required to submit data on this measure for the purposes of the IRF QRP beginning with patients discharged on or after October 1, 2018. - The IRF-PAI data items associated with reporting this measure (O0250A, O0250B, and O0250C) will be removed from the IRF-PAI version 3.0 effective October 1, 2019. Until then, CMS is instructing providers to enter a dash (–) for these items. Per AMRPA’s request, CMS will provide ongoing guidance to providers to clarify that use of a dash for these assessment items is appropriate starting October 1, 2018, and will not cause a noncompliance determination. CMS estimates that removing these measures will save providers $2.5 million in reporting costs in FY 2019. AMRPA had previously recommended that CMS remove these measures due to their low incidence rate in IRFs and are pleased to see their removal. AMRPA additionally suggested that CMS consider removing additional measures from the IRF QRP, including the NHSN Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138) and the NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717). CMS states it will take these suggestions into consideration as it engages in future measure selection activities for the IRF QRP. 2. Proposed Public Display of Functional Outcomes Measures Data on IRF Compare CMS finalized its proposals to begin publicly displaying data on the following four assessment-based measures in CY 2020, or as soon thereafter as technically feasible: • IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients (National Quality Forum (NQF) measure #2633); • IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634); • IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635); and • IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636).

The displayed data will be based on four rolling quarters of data initially using discharges from January 1 through December 31, 2019. Providers with fewer than 20 cases during any of the four consecutive rolling quarters will not have their data displayed due to statistical reliability. AMRPA asked CMS to educate providers about how provider performance on the functional outcomes measures are calculated and how the data will be reported to the public. In response, CMS states that it plans to provide data on the measures, including patientlevel data, risk-adjusted data (such as the intercept and coefficient values used in risk-adjustment) via providers’ CASPER reports in the fall of 2018. CMS also intends to provide training to assist IRFs in interpreting those data and about how the data will be publicly reported. 3. Proposed Changes to Reconsideration Requirements under the IRF QRP CMS is finalizing its proposal to modify its policies for notifying IRFs of non-compliance with the IRF QRP requirements to also include an email from the provider’s Medicare Administrative Contractor (MAC) as a notification method. With this change, CMS states that it will notify providers of non-compliance with a letter sent through at least one of the following notification methods: via an email from the MAC, the QIES-ASAP system, or the United States Postal Services. CMS will also notify IRFs of its final decision regarding any reconsideration request using the same notification method. Although this policy is formally effective October 1, 2018, AMRPA is aware that CMS has been using MACs to send non-compliance notices for several years. Furthermore, members have reported that the MACs lack sufficient understanding about the IRF QRP, what specific quality measures or time periods are causing the non-compliance determination, or how to further assist providers seeking to pursue a reconsideration request. AMRPA will be working with CMS to ensure that this process is improved in future years. D. Changes to the IRF PPS Payment Rates for FY 2019 1. Update to the CMG Weights and Average Lengths of Stay for FY 2019 As it does annually, CMS proposed to update Case Mix Group (CMG) weights and average lengths of stay (ALOS) figures using FY 2016 IRF cost report data and the FY 2017 IRF claims data. However, CMS also frequently has new data become available between the proposed and final rule. Using more recent data that became available since the proposed rule, CMS finalized slightly adjusted CMG weights and ALOS, which are found in Table 2 of the final rule. CMS continues to estimate that 99.3 percent of all IRF cases are in CMGs and tiers that would experience less than a five percent change in the CMG relative weight under this proposal.

Table 3. Distributional Effects of the Proposed Changes to the FY 2019 CMG Relative Weights [FY 2018 values compared with FY 2019 values] Percentage change in CMG relative weights

Number of cases affected

Percentage of cases affected

Increased by 15% or more

0.0

Increased by between 5% and 15%

1,600

0.4

Changed by less than 5%

394,149

99.3

Decreased by between 5% and 15%

1,193

0.3

Decreased by 15% or more

0.0

2. Market Basket Update and Standard Payment Rate CMS finalized the standard rate conversion factor for FY 2019 at $16,021, which is a 1.16 percent increase from the FY 2018 standard payment rate conversion factor of $15,838. This increased amount is the result of a 2.9 percent rehabilitation-specific market basket update, which is reduced by a mandated 0.8 percentage productivity adjustment, a 0.75 percent reduction as required by the Affordable Care Act, and a small budget neutrality adjustment for the CMG relative weights due to changes made to those weights. Table 6 in the final rule provides the payment rates for all FY 2019 CMGs after applying the updated standard conversion factor and CMG relative weights, but without the facilityspecific adjusters. Table 5. Calculations to Determine the Proposed FY 2019 Standard Payment Conversion Factor Explanation for adjustment

Calculations

Standard Payment Conversion Factor for FY 2018

$15,838

Market Basket Increase Factor for FY 2019 (2.9 percent), reduced by 0.8 percentage point for the productivity adjustment as required by section 1886(j)(3)(C)(ii)(I) of the Act, and reduced by 0.75 percentage point in accordance with sections 1886(j) (3)(C)(ii)(II) and 1886(j)(3)(D)(v) of the Act

x 1.0135

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

x 1.0000

Budget Neutrality Factor for the Revisions to the CMG Relative Weights

x 0.9980

Proposed FY 2019 Standard Payment Conversion Factor

= $16,020

3. Labor Related Share and Wage Adjustments The finalized labor-related share of IRFs’ payments for FY 2019 is 70.5 percent, a slight decrease from 70.7 percent in FY 2018. This decrease is attributable to a 0.1 percent decrease in the subcategories of employee benefits and wages and salaries, two of the factors that make up the labor-related share of hospital costs. CMS had originally

AMRPA Magazine / August 2018 23

proposed a labor-related share of 70.6, but says the most recently available data indicated a 0.01 percentage drop in wages and salaries, and it adjusted its final policy accordingly. CMS is also finalizing its proposal to use the FY 2018 pre-reclassification and pre-floor acute care hospital wage index, which is a one-year lag from what acute-care hospitals receive and is consistent with previous years. 4. O utlier Threshold and Cost-To-Charge Ratio CMS proposed to update the outlier threshold amount from $8,679 for FY 2018 to $10,509 for FY 2019 to ensure outlier payments account for three percent of total payments. However, since the proposed rule, CMS says the most recent data shows outlier payments for FY 2018 will be lower than it had previously estimated. Therefore, the final high-cost outlier threshold for FY 2019 is $9,402. Further, the final cost-to-charge (CCR) ceiling is 1.32 for FY 2019, and the national average CCR is 0.515 for rural IRFs and 0.412 for urban IRFs. 5. Changes to Facility Adjusters CMS made significant changes to the methodology used to develop the facility-level adjustment factors in the

24 AMRPA Magazine / August 2018

FY 2014 IRF PPS final rule. For FY 2019, CMS continues to freeze the low-income pool (LIP), rural and teaching adjustments at the FY 2014 levels, which are: â&#x20AC;˘ LIP factor: 0.317 â&#x20AC;˘ Rural adjustment: 14.9 percent â&#x20AC;˘ Teaching adjustment: 1.0163. E. Request for Information on Promoting Interoperability through Possible Revisions to the Conditions of Participation CMS sought feedback on the possibility of revising the CoPs as a way to encourage electronic sharing of health data between providers. Specifically, the agency stated it might consider revisions to the current CMS CoPs that would require hospitals to electronically transfer medically necessary information to another facility or community provider upon a patient transfer or discharge. CMS also discussed requiring that hospitals make certain information available to patients or a specified third-party application (for example, required discharge instructions) via electronic means if requested. Due to the fact that this was just a request for information, CMS did not respond to comments but did acknowledge and thanked providers for their input..

FAIR FUND Fund for Access to Inpatient Rehabilitation

HAVE A HAND IN THE SOLUTION

NEW AND CURRENT MEMBER BENEFIT! Updated compendium of Medicare audit and appeals resources, including electronic template appeals with the latest legal arguments for coverage.

LEARN MORE & JOIN TODAY www.thefairfund.org We are the Fund for Access to Inpatient Rehabilitation, a Common Legal Defense Fund Composed of Americaâ&#x20AC;&#x2122;s Top Inpatient Rehabilitation Hospitals and Units. Fighting Restrictive Medicare Policies â&#x20AC;˘ Challenging Aggressive Contractors We need all IRFs to lend a hand in challenging aggressive Medicare auditors in order to level the playing field, and preserve and enhance patient access to IRF care. For more information, or to speak with a FAIR Fund leader or staff member, contact Rebecca Schnorf at rschnorf@firminc.com or at (217) 321-2477.

AMRPA Magazine / August 2018 25

REGISTRATION OPEN www.amrpa.org

Begin with our pre-conference IRF Boot Camp

Then enter our concurrent tracks: Business Operations & Leadership Development Clinical Care & Delivery: A Team Approach Regulatory, Legislative, and Accreditation Matters Marketing and Relationship Management & Outside the Box

FY 2019 SNF Final Rule Includes Major Changes for Nursing Home Payment System On July 31, the Centers for Medicare and Medicaid Services (CMS) issued the federal fiscal year (FY) 2019 final rule updating Medicare payment policies and rates under the Skilled Nursing Facility Prospective Payment System (SNF PPS), the SNF Quality Reporting Program (SNF QRP), and the SNF Value-Based Purchasing (SNF VBP) Program.

Mimi Zhang, Senior Policy and Research Analyst

Highlights: »» »»

New Patient Driven Payment Model (PDPM) will replace the current Resource Utilization Group (RUG-IV) payment system in FY 2020. Aggregate payments to skilled nursing facilities proposed to increase by $820 million in FY 2019.

Most notably, CMS finalized a new payment system for SNFs effective October 1, 2019 (FY 2020). The Patient-Driven Payment Model (PDPM) is intended to reduce Medicare spending and improve care by tying payments to resident conditions rather than the minutes of therapy provided. Akin to the payment system changes finalized for inpatient rehabilitation hospitals and units (IRFs) in this IRF PPS rule, the PDPM is a significant step toward CMS’ goal of basing post-acute care payments on the standardized crosssetting patient assessment data collected pursuant the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. Based on the rule’s final policies, CMS estimates that the FY 2019 aggregate impact will be an increase of $820 million in Medicare payments to SNFs, due to the Bipartisan Budget Act of 2018 (BBA of 2018), which requires the FY 2019 SNF market basket update to be 2.4 percent. CMS states that without this statutory requirement, the FY 2019 market basket update factor would have been 2.0 percent. Patient-Driven Payment Model The PDPM uses ICD-10 diagnosis codes and other patient characteristics as the basis for patient classification and adjusts payment based on five aspects of a resident’s care: 1. Physical therapy (PT) 2. Occupational therapy (OT) 3. Speech-language pathology (SLP) 4. Nursing, which covers utilization of nursing services and social services 5. Non-therapy ancillary (NTA) services (items and services not related to the provision of therapy such as drugs and medical supplies). Payment is calculated by multiplying the case-mix index for the resident’s group with each component, first by a base payment rate and then by days of service received. The payment calculations for each component would then be added together to create a resident’s total per diem rate. The PDPM adjusts the SNF per diem payments to reflect varying costs throughout the stay and incorporates safeguards against potential financial incentives.

AMRPA Magazine / August 2018 27

CMS states that the proposed PDPM reflects an approximately 80 percent reduction in the number of payment group combinations compared to an earlier version of a revised payment model, the RCS-1. CMS believes that the PDPM would move Medicare toward a more value-based, unified post-acute care payment system while also reducing facilities’ administration burden. CMS also adopted additional therapy reporting requirements to the Minimum Data Set (MDS) discharge assessment focused on 1) documenting a resident’s therapy minutes and therapy modes, and 2) the days for each discipline and mode of therapy. Since the inception of the SNF PPS, CMS has limited the amount of group therapy to each Medicare Part A resident to 25 percent of the therapy provided to them by discipline. Per this rule, CMS is now placing a combined limit on group and concurrent therapy to no more than 25 percent of a resident’s therapy minutes by discipline. CMS states that it intends to monitor SNFs’ compliance with the new group and concurrent therapy limits through the new therapy documentation requirements. SNF Quality Reporting Program (QRP) and Value-Based Purchasing (VBP) Program CMS will publicly display data for the self-care and mobility function measures in CY 2020; SNFs begin submitting data on the measures beginning October 1, 2018. The measures are: Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633);

Application of IRF Functional Outcome Measure Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634); Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635); and Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636). CMS adopted its proposal to increase the number of years of data used to publicly display two claims-based SNF QRP measures, Discharge to the Community and Medicare Spending per Beneficiary, from one year to two years. CMS also adopted an additional factor to consider when evaluating measures for removal from the SNF QRP measure set. This factor takes into account costs that are associated with a measure and weighs them against the benefit of its continued use in the program. Beginning October 1, 2018, the SNF VBP Program will apply either positive or negative incentives on facilities’ payment based on their performance on the SNF all cause 30-day hospital readmissions measure. Changes adopted in this rule for the SNF VBP Program include an updated scoring methodology for lowvolume providers and a revised extraordinary-exemption policy.

Let’s Stay in Touch

AMRPA has new phone and fax numbers. Please see the changes below to update your records. AMRPA Government Relations & Policy Team AMRPA Main Phone: 202-591-2469 Fax: 202-591-2445

Mimi Zhang, AMRPA Senior Policy and Research Analyst Direct Phone Line: 202-860-1003

Carolyn Zollar, JD, MA, AMRPA EVP for Government Relations and Policy Development Direct Phone Line: 202-860-1002

Lovelyn Robinson, AMRPA Editorial and Research Assistant Direct Phone Line: 202-860-1005

Jonathan Gold, JD, AMRPA Regulatory and Government Relations Counsel Direct Phone Line: 202-860-1004

28 AMRPA Magazine / August 2018

Catherine Beal, AMRPA Staff Associate Direct Phone Line: 202-860-1006

MedPAC Issues 2018 Data Book on Medicare Utilization and Spending Trends

Mimi Zhang, Senior Policy and Research Analyst

The Medicare Payment Advisory Commission (MedPAC) recently published its annual compendium of Medicare utilization and payment information, “June 2018 Data Book: Health Care Spending and the Medicare Program.” The volume presents updated statistics from 2016 on national health care and Medicare expenditures, beneficiary demographics, provider settings, multiple metrics of utilization rates and care quality, and providers’ Medicare profit margins, if applicable. This article presents select tables and summary findings from the data book of relevance to inpatient rehabilitation hospitals and units (IRFs) and other post-acute care (PAC) providers.

Chart 1-2: Medicare spending is concentrated in certain services and has shifted over time

MedPAC’s observations: In 2016, Medicare spending totaled $663 billion for benefit expenses. Managed care (Medicare Advantage) was the largest spending category (28 percent of total 2016 outlays), having increased by 47 percent between 2007 and 2016. Medicare managed care enrollment increased 112 percent over the same time period (data not shown). Spending for inpatient hospital services was a smaller share of total Medicare spending in 2016 than it was in 2007, falling from 29 percent to 21 percent.

AMRPA Magazine / August 2018 29

Chart 8-1: Number of post-acute care providers decreased slightly or remained stable in 2016

HHAs

2016-2017 Percent change

2011

2013

2015

2016

2017

10,961

12,026

12,613

12,346

12,204

11,844

-1.6%

1,196

1,165

1,161

1,182

1,188

1,178

0.4

-0.8

427

437

432

426

423

411

-1.2

-2.8

15,062

15,120

15,163

15,223

15,263

15,277

0.2

0.1

IRFs LTCHs SNFs

2013-2016 Average annual percent change

2009

Post-Acute Care The supply of IRFs has been relatively stable since 2013. Most inpatient rehabilitation providers are distinct units in acute care hospitals, and only about one-fifth of IRFs are freestanding hospitals. However, because hospital-based units tend to have fewer beds, they account for only about half of Medicare discharges from IRFs. The number of home health agencies (HHAs) has been declining since 2013 after several years of substantial growth. The decline was concentrated in Texas and Florida, two states that have seen considerable growth since the implementation of the HHA prospective payment system in October 2000. Although a moratorium on new long-term care hospitals (LTCHs) led to a decrease in the number of LTCHs beginning in 2012, the number of LTCHs further declined to 211 in 2017. MedPAC attributes this drop primarily to the implementation of a payment policy that reduces payment for discharges not meeting certain criteria. The total number of skilled nursing facilities (SNFs) has increased slightly since 2009, and the mix of facilities shifted from hospital-based to freestanding facilities. In 2017, hospital-based facilities made up 5 percent of all facilities, down from 8 percent in 2005.

Chart 8-2: Growth in Medicare’s fee-for-service post-acute care expenditures has slowed since 2011

Increases in FFS spending on PAC have slowed in part because of growing enrollment in managed care under Medicare Advantage (Medicare Advantage is not included in this chart). Since 2012, growth in FFS PAC spending has remained flat. The slowest growth in FFS spending on post-acute care occurred between 2012 and 2014. FFS spending on IRFs declined from 2004 through 2008, reflecting payment policy changes during that period. However, spending on IRFs has increased since increased, rising from $6.0 billion in 2008 to $7.7 billion in 2016. In 2016, Medicare’s combined spending on SNFs and HHAs constituted almost 50 percent of total PAC spending. (SNF spending: 29.1 percent; HHA spending: 18.3 percent). Chart 6-18: Discharge destination of Medicare fee-for-service (FFS) beneficiaries, 2006-2016

Destination

2006

2015

2016

Percent change 2006 to 2015

Home self-care

52.3%

46.0%

45.6%

–6.7%

Skilled nursing or swing bed

18.8

21.2

20.2

1.4

Home with organized home health care

13.8

16.9

17.5

3.7

Inpatient rehabilitation facility

3.4

3.9

4.0

0.6

Died in hospital

3.8

3.3

–0.5

Hospice

1.6

2.9

3.0

1.4

Transferred to other acute care hospital

2.5

2.2

1.9

–0.6

Other setting (e.g., ICF*, nursing facility)

2.0

1.6

2.0

–0.0

Long-term care hospital

0.9

1.2

0.3

Left against medical advice

0.6

0.8

0.9

0.3

Inpatient psychiatric facility

0.4

0.5

0.4

0.0

*Intermediate care facility

30 AMRPA Magazine / August 2018

-3.0%

Medicare margins of PAC providers, 2004-2016 2004

2006

2008

2010

16.7%

19.4%

14.1%

12.87%

11.4%

9.3

8.7

11.1

12.5

13.0

19.4

14.4

10.8

15.5

6.7

7.6

5.1

4.1

SNF (freestanding)

13.8%

12.8%

IRF

16.7

12.4

HHA (freestanding)

15.4

9.7

LTCH

17 3.6

2012

2014

2016

Chart 8-12: Number of IRF FFS patients increased in 2016

Number of IRF cases Cases per 10,000 FFS beneficiaries Payment per case Average length of stay (days)

2008

2013

2015

2008-2015 Average annual percent change

2015-2016 Percent change

356,000

373,000

381,000

391,000

1.0%

2.4%

100.4

99.1

101.0

101.7

0.0

1.4

$16,646

$18,258

$19,116

$19,714

2.0

3.1

13.3

12.9

12.7

-0.6

0.0

In 2015, about 43 percent of all Medicare FFS patients discharged from an acute care hospital were discharged to PAC services (IRF, SNF, LTCH or HHA). The share of beneficiaries discharged to PAC increased about 6 percent between 2006 and 2015. About 5 percent of beneficiaries are discharged to hospital-level PAC in an inpatient rehabilitation facility (4.0 percent) or longterm care hospital (1.2 percent). A growing proportion of patients are being discharged home with organized home health care, from 13.8 percent in 2006 to 20.2 percent in 2016. MedPAC analyzes Medicare margins and uses them as a basis to recommend annual updates, or the lack thereof, for various sectors. It also examines the sectors’ strengths based on other metrics such as number of providers, beneficiary access to care, discharges, providers’ access to capital, quality of care, etc. Inpatient Rehabilitation Providers The number of IRF FFS cases grew rapidly throughout the 1990s and the early years of the IRF prospective payment system, reaching a peak of about 495,000 in 2004 (data not shown). Medicare payments per IRF case rose, on average, 2.0 percent per year between 2008 and 2015. Average payment per case grew 3.1 percent between 2015 and 2016. After CMS renewed its enforcement of the compliance threshold in 2004, IRF volume declined substantially. Between 2004 and 2008, the number of IRF cases fell almost 8 percent per year. From 2008 to 2014, IRF volume increased less than 1 percent per year on average. Between 2015 and 2016, volume growth picked up, rising 2.4 percent. Stroke patients were the most frequent diagnosis for IRF patients in 2015, accounting for 20.1 percent of all Medicare FFS IRF admissions. The percentage of major joint replacements of the lower extremity has steadily decreased in the past decade; notably in 2016, cardiac conditions (6.1 percent) surpassed major lower extremity joint replacements (5.5 percent) for the first time. In 2004,

Chart 8-13: Most common IRF cases from 2014 to 2016 2014

2015

2016

19.5%

19.8%

20.1%

Other neurological disorders

13.1

13.0

13.7

Fracture of the lower extremity

12.2

11.5

10.8

Debility

10.3

10.7

Brain injury

8.7

9.3

9.9

Other orthopedic conditions

7.7

7.9

8.2

Cardiac conditions

5.6

6.0

6.1

Major joint replacement of lower extremity

7.8

6.8

5.5

Spinal cord injury

4.6

4.7

4.9

All other

10.6

10.5

10.1

Stroke

major joint replacements were the most common IRF case and accounted for 24 percent of all admissions. MedPAC notes that the number and share of neurological conditions has grown significantly over the past decade. Between 2008 and 2015, the number of neurological cases increased 76 percent while the total number of Medicare IRF cases grew 9 percent (data not shown). In 2004, other neurological conditions constituted 5.2 percent of total IRF cases (data not shown). Quality of Care MedPAC and its contractor, the Urban Institute, have developed several measures to evaluate the quality of care in various settings, including SNFs and IRFs. Though some of MedPAC’s measures appear similar to those in CMS’ IRF or SNF Quality Reporting, such as discharge to community or rehospitalizations (readmissions) measures, they differ in their technical details and therefore are not identical to CMS’ measures. For the tables below, high rates of discharge to community indicate better quality whereas lower readmission rates indicate better quality.

AMRPA Magazine / August 2018 31

Chart 5-3: IRFs improved on risk-adjusted rates of discharge to the community and potentially avoidable rehospitalizations from 2011 to 2016 Measure

2011

2012

2014

2015

2016

Potentially avoidable rehospitalizations during IRF stay

2.9%

2.6%

2.5%

2.4%

2.5%

Potentially avoidable rehospitalizations 30 days after IRF discharge

5.0

4.6

4.5

4.2

4.4

74.0

75.2

76.2

76.0

76.9

6.9

6.7

6.9

6.8

6.7

Discharge to the community Discharged to a SNF

Source: MedPAC analysis of Medicare claims data and IRF Patient Assessment Instrument (IRF PAI) data.

Chart 5-1: SNFs improved on some quality measures but not others from 2011-2016 Measure

2011

2012

2014

2015

2016

Discharge to the community

33.2%

35.6%

37.6%

38.7%

39.5%

Potentially avoidable rehospitalizations during SNF stay

12.4

11.4

10.8

10.4

10.8

Potentially avoidable rehospitalizations 30 days after SNF discharge

5.9

5.6

5.0

5.8

Rate of improvement in one or more mobility ADLs

43.6

43.4

43.6

Rate of no decline in mobility

87.2

87.3

87.1

Source: MedPAC analysis of Medicare claims and Minimum Data Set (MDS) data.

MedPAC’s IRF rehospitalization rates count only stays readmitted to a hospital with the principal diagnosis of a potentially avoidable condition. These potentially avoidable rehospitalizations conditions include: respiratory-related illness (pneumonia, influenza, bronchitis, chronic obstructive pulmonary disease and asthma), sepsis, congestive heart failure, fractures or fall with a major injury, urinary tract or kidney infection, blood pressure management, electrolyte imbalance, anticoagulant therapy complications, diabetesrelated complications, cellulitis or wound infection, pressure ulcer, medication error or adverse drug reaction, and delirium. Between 2012 and 2016, the average IRF risk-adjusted community discharge rate increased from 75.3 percent to 76.9 percent (higher rates are better). Similar to the IRF QRP Discharge to Community measure, MedPAC’s measure also does not give IRFs credit for discharging a Medicare beneficiary to the community if the beneficiary is subsequently readmitted to an acute care hospital within 30 days of the IRF discharge.

MedPAC’s SNF readmission rates include only patients readmitted to a hospital with the principal diagnosis of one of 13 potentially avoidable conditions. The conditions are: congestive heart failure, electrolyte imbalance/dehydration, respiratory infection, sepsis, urinary tract or kidney infection, hypoglycemia or diabetic complications, anticoagulant complications, fractures and musculoskeletal injuries, acute delirium, adverse drug reactions, cellulitis/wound infections, pressure ulcers, and abnormal blood pressure. The functional status measures were essentially unchanged between 2011 and 2016. The mobility measures are composites of the patients’ abilities in bed mobility, transfer, and ambulation, and they reflect the likelihood that a patient will change, given his or her functional ability at admission. A facility admitting patients with worse prognoses will have a lower expected rate of achieving these outcomes, and this difference will be reflected in the risk-adjusted rates. The rate of improvement in mobility shows the share of stays with improvement in one, two, or three ADLs: bed mobility, transfer and ambulation. The rate of no decline in mobility is the share of stays with no decline in any of the three ADLs. The complete Data Book is available at www.medpac.gov.

32 AMRPA Magazine / August 2018

HHS Inspector General Finds Weaknesses in Medicaid Managed Care Organizations’ Fraud Prevention Efforts

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

Highlights: »»

Some organizations did not identify any fraud for an entire year.

»»

OIG recommends increased oversight and guidance by CMS to stop fraud.

// The OIG determined the median number of cases identified by the 38 MCOs was 106 in 2015. However, the survey showed seven MCOs identified fewer than 30 cases of suspected fraud or abuse, and two of these MCOs did not identify a single case during the year.

The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) released a report on July 11, 2018, examining Medicaid Managed Care Organizations’ (MCOs) fraud detection and prevention efforts. In this investigation, the OIG aimed to examine the extent to which Medicaid MCOs identify, address and refer cases of suspected fraud or abuse, the extent to which MCOs inform state authorities about suspected fraud and abuse, and the extent to which MCOs recover overpayments.

To conduct this review, the OIG conducted a survey requesting 2015 data from the MCO with the largest expenditures in each of the 38 states that provides Medicaid services through managed care. The OIG also conducted structured interviews with officials from five selected MCOs, as well as authorities from the states overseeing those MCOs. The results of the survey showed that the 38 MCOs varied widely in the number of suspected fraud and abuse cases they identified. The OIG determined the median number of cases identified by the 38 MCOs was 106 in 2015. However, the survey showed seven MCOs identified fewer than 30 cases of suspected fraud or abuse, and two of these MCOs did not identify a single case during the year. In contrast, three MCOs identified more than 800 cases each, according to the survey. The OIG also found large discrepancies in the amount of cases that were referred by MCOs to the state for further investigation or action. The OIG found a third of MCOs referred fewer than 10 cases of suspected fraud or abuse to the state in 2015 while four

AMRPA Magazine / August 2018 33

MCOs each referred more than 100 cases to the state during the year. The OIG did note that with regard to reporting fraud and abuse, states have different standards for when an MCO is supposed to report fraud to the government. In addition, the OIG found that MCOs did not do a consistently adequate job of recovering overpayments of suspected fraud. In total, the 38 MCOs identified $57.8 million in overpayments in 2015 and the median amount identified was $402,000 per MCO. However, four of the MCOs identified no overpayments. Overall, MCOs recovered overpayments equal to 22 percent of the amount they identified. Seven of these MCOs recovered overpayments equal to two percent or less of the amount they identified, whereas six MCOs recovered the full amount they identified in 2015. The OIG drew several conclusions based on the information it collected. First, it concluded that the two biggest weaknesses identified through this study was that many MCOs found and referred few cases of suspected fraud or abuse, and that many MCOs identified and recovered few overpayments. The OIG said that these weaknesses suggest that MCOs need additional incentives to identify and refer cases and to recover overpayments. The OIG also said that MCOs and states must work more closely together to coordinate on fraud fighting efforts.

The OIG made several more specific recommendations, enumerated below: 1. CMS should provide technical assistance to states and share best practices with them to improve MCOsâ&#x20AC;&#x2122; efforts to identify and refer cases of suspected fraud or abuse. 2. CMS should work with states to increase MCO reporting of actions that MCOs take against providers suspected of fraud or abuse. 3. CMS should work with states to clarify the information that MCOs should report to the state when a providerâ&#x20AC;&#x2122;s status changes due to fraudulent activity. 4. CMS should identify and share best practices about payment retention policies and incentives to increase recoveries. 5. CMS should provide assistance to states to help facilitate improvement of communication and coordination between MCOs and state- level program integrity entities. 6. CMS should work with state to standardize referrals across MCOs in the state. 7. CMS should work with states to improve submission of complete, accurate, and timely encounter data by MCOs and monitor encounter data submitted by states and impose penalties on states for submitting inaccurate or incomplete encounter data. CMS concurred with all but the recommendation that it should work with states to standardize the reporting of referrals in the state. Read the entire report on the OIG website at www.oig.hhs.gov.

34 AMRPA Magazine / August 2018

CMS Releases 2019 Physician Fee Schedule Proposed Rule; Proposes Changes to Therapy Reporting and E/M Codes

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

Highlights: »»

»»

Therapists would no longer be required to report functional progress. E/M proposal would consolidate payments for level 2-5 outpatient visits.

On July 12, the Centers for Medicare and Medicaid Services (CMS) released the Physician Fee Schedule (PFS) proposed rule for calendar year (CY) 2019. Of note to rehabilitation providers, CMS is proposing to remove functional reporting requirements for outpatient therapy services and is also proposing, as directed by statute, to define how it will apply a payment reduction for therapy services that involve a therapy assistant. In addition, CMS is proposing sweeping changes to the Evaluation and Management (E/M) payment rates and documentation requirements for outpatient physician visits. This article takes a section-by-section look at some of the proposals included in this rule.

// CMS says it no longer believes it is necessary to continue collecting the data because the data was originally intended to inform future changes to the outpatient therapy caps, which have now been repealed, and because the agency had not found the data particularly insightful.

Repeal of the Therapy Caps and Functional Reporting Requirements The Bipartisan Budget Act of 2018 (BBA of 2018) repealed the Medicare outpatient therapy caps and the therapy cap exceptions process. While CMS is continuing to require a KX modifier for services above the threshold, as required by statute, it is proposing to eliminate functional reporting requirements for outpatient therapy services. Since January 1, 2013, all providers of outpatient therapy services, including physical therapy (PT), occupation therapy (OT) and speech-language pathology (SLP) services, have been required to include functional status information on claims for therapy services.

AMRPA Magazine / August 2018 35

CMS says it no longer believes it is necessary to continue collecting the data because the data was originally intended to inform future changes to the outpatient therapy caps, which have now been repealed, and because the agency had not found the data particularly insightful. The change is also in response to requests from stakeholders seeking documentation burden reduction. Therefore, CMS is proposing to eliminate the requirement that therapists include G-codes and appropriate modifiers in claims for outpatient therapy services beginning January 1, 2019. Reduction in Payment and New Modifiers for Therapy Assistants The BBA of 2018 also instituted a reduced payment rate of 85 percent of the otherwise applicable Part B payment for any therapy services provided in whole or in part by a therapy assistant. The new payment rate does not take effect until January 1, 2022, but the act requires CMS to develop a modifier for services provided in whole or part by a therapy assistant by January 1, 2019, and also mandates the modifier begin to be used by January 1, 2020. Currently, there are three modifiers – GP, GO and GP – used to distinguish therapy services provided under a PT, OT or SLP plan of care, respectively. In order to distinguish therapy services delivered entirely by a therapist from services provided with the participation of a therapy assistant, CMS proposes to create two new modifiers. CMS does not indicate what those modifiers will be, but says this would mean there would be five total modifiers – GP, GO and SLP (for use when only when the services are provided in whole by the therapists) and two new modifiers for use when a therapy assistant delivers the OT or PT services, even in part. CMS says it does not believe there is such thing as a SLP assistant, so it is not creating a sixth modifier. CMS also provides a definition of “in part” for when an assistant modifier needs to be used and when payment will be downwardly adjusted. It proposes that whenever the therapy assistant is involved in any minute of the therapeutic portion of the service, the claim must be billed with the new therapy assistant modifier. It further clarifies “therapeutic” by saying that it includes everything except activities that someone without training of an assistant could do, such as scheduling, cleaning the room or robing the patient, and any other participation by the assistant would trigger the need for the assistant code and payment adjustment. Evaluation and Management (E/M) Visit Code Payment and Documentation CMS is proposing significant changes to the Evaluation and Management (E/M) codes used by physicians and advanced practice clinicians (APCs) to bill office and other outpatient visits (CPT Codes 99201-99205 & 99211-99215). Currently, a physician or an APC (referenced hereinafter jointly as “practitioners”) will bill one of five E/M codes depending on the level of the visit, for visits taking place in an office or outpatient settings. There are two distinct set of the five codes: one for new patients (99201-99205) and one for established patients (99211-99215). Practitioners determine which level of visit to bill based on guidelines from the American Medical Association (AMA). The 36 AMRPA Magazine / August 2018

AMA guidelines instruct practitioners to choose which of the five levels to code the visit based on three factors, including history of present illness (HPI), physical examination and medical decision making (MDM). The level of code generally increases as time, resources used or complexity of the patient increases, with level one being the lowest and level five being the highest. Payments increase as the level of the visit increases. Payment Changes CMS is proposing to consolidate payment levels two through five of the current outpatient E/M codes, so that any level above one receives the same payment amount, effective CY 2019. CMS states that the current guidelines, with inputs based on HPI, exams and MDM, may not do a good job of capturing the actual intensity and resource use of visits. CMS says consolidating the payments for these visits will allow it to loosen documentation requirements, as discussed more fully below, and not have to perform as many audits of billing practices. Tables 19 and 20 from the proposed rule below show the current rates for visit levels two through five compared with CMS proposal for the new, consolidated payment rates. Table 19: Preliminary Comparison of Payment Rates for Office Visits New Patients CY 2018 Non-facility Payment Rate under the Proposed Methodology

HCPCS Code

CY 2018 Non-facility Payment Rate

99201

$45

$44

99202

$76

$135

99203

$110

99204

$167

99205

$211

Table 20: Preliminary Comparison of Payment Rates for Office Visits Established Patients HCPCS Code

Current Non-facility Payment Rate

Proposed Non-facility Payment Rate

99211

$22

$24

99212

$45

$93

99213

$74

99214

$109

99215

$148

In order to accommodate E/M visits that may be either over or under compensated based on this consolidation, as well as to address existing shortcomings in the code system, CMS has proposed a number of new adjustment codes that provide an add-on or reduction in payments on top of the new E/M payment rates. The first adjustment CMS proposes is a multiple procedure payment reduction (MPPR). This MPPR would be required to be applied to any E/M visit that occurs on the same day and by the same practitioner as a separately billed procedure. Practitioners would need to apply appendix modifier “-25,” and would have their payment for the least expensive of the two billed services reduced by 50 percent.

The second adjustment CMS is proposing is G-code GPC1X, which would be used to indicate the E/M visit involved complexity inherent in the services associated with primary medical care. CMS says it would expect practitioners to add this code when serving in the primary care role for a patient and billing an E/M code in levels 2 through 5. CMS seeks comment on how to best determine whether the visit was in fact a primary care visit. The agency says it recognizes that some specialist practitioners also perform primary care services, and it would not limit the use of the code to certain clinician types. The next adjustment code is for use by certain specialties that CMS states more typically bill at levels four or five under the current system. CMS says it chose these specialties because, based on their billing patterns, it appears these types of practitioners “apply predominantly non-procedural approaches to complex conditions that are intrinsically diffuse to multi-organ or neurologic diseases.” Physical Medicine and Rehabilitation is not included as a specialty on this list. CMS is also proposing a new G-code for prolonged services when the E/M service requires more than the typical service time. This code will be GPRO1, and will be described as: “Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; 30 minutes [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service]).” CMS seeks comment on when exactly the prolonged time code may be used. Documentation Changes CMS is proposing to add two additional options for determining which level an E/M visit should be billed. The first option is to rely solely on the MDM aspect of the guidelines to determine which level to bill, and not factor in HPI and exam factors. Under this approach, the practitioner would only need to have documentation matching the MDM aspect of the visit in order to clear an audit for the claim. CMS says it also believes the MDM aspects of the guidelines are outdated, and seeks comment on how it can update those guidelines in future years. The second new option CMS is proposing is to allow the practitioner to choose the level of the visit based solely on the time involved in the visit. Under this option, CMS would require the practitioner to generally document the medical necessity of the claim and also the total time spent on the visit. CMS presents several options it is considering for the amount of time that must be spent to submit a claim at level two or above. Its first proposal is 31 minutes for an established patient and 38 minutes for a new patient. These times are weighted averages of the “typical” intraservice times across the current E/M codes for levels two through five. CMS points out that these times in the E/M codes have always been referred to in the past as “typical” and not required. The second time option CMS presents is the AMA’s CPT codebook provision that says for timed services, a unit of time is attained when the mid-point is passed. CMS says under this model it would require documentation of 16 minutes for an

established patient (more than half of 31 minutes) and at least 20 minutes for a new patient (more than half of 38 minutes). The final option CMS presents for the time option is to require documentation that the typical time for the CPT code that is reported (which is also the typical time listed in the AMA’s CPT codebook for that code) was spent with the patient. For example, a practitioner reporting CPT code 99212 (a level 2 established patient visit) would be required to document having spent a minimum of 10 minutes, and a practitioner reporting CPT code 99214 (a level 4 established patient visit) would be required to document having spent a minimum of 25 minutes. CMS makes clear that practitioners may continue to use the current AMA guidelines as they always have to document E/M visits. Further, CMS says it expects clinicians to continue to use all five of the E/M visit codes in an appropriate manner, but that practitioners may have more flexibility to forgo certain documentation when choosing one of the new, alternative guidelines. CMS also specifically requests comment on the practicality of utilizing these alternative guidelines based on how they might interact with current electronic health records (EHR) systems, continuity of care, clinical workflows and other aspects of care. In addition to using alternative guidelines based solely on time or MDM, CMS is also proposing to only impose documentation requirements at the level currently required for level 2 E/M visits (according to AMA guidelines) for all claims. This means that CMS continues to expect practitioners to choose the appropriate E/M code based on the visit level, but they would no longer have to document beyond what is currently required of level 2 visits. The only exception to this is for practitioners who choose a level based on time, which must be documented appropriately as described above. Further, this new, lower level of documentation applies even if practitioners continue to use the full AMA guidelines incorporating HPI, exam and MDM, as was previously required. CMS says it expects many practitioners will continue to provide documentation beyond level two requirements as it may be necessary for quality, continuity of care or legal purposes. However, as discussed previously, if CMS finalizes its proposals, there will be no pay differential between levels 2 and 5, regardless of how much documentation is provided by the practitioner and regardless of which of the three options the practitioner chooses to base their decision of level of visit upon. Other Sites of Care As previously stated, CMS is only proposing to implement these changes for E/M codes for outpatient and office visits. CMS says it has heard similar complaints about E/M code guidelines for other settings, including inpatient, but it is concerned that changes to hospital codes will be especially complicated. CMS cites many reasons for this, including some of the Conditions of Participation regulations or other regulations governing hospitals require certain medical record standards. CMS seeks comments broadly on how it should proceed with reforms to the E/M visit guidelines for other settings, including how to navigate other regulations governing medical records and payment.

AMRPA Magazine / August 2018 37

Further Documentation Reduction In addition to the other changes proposed to E/M visit documentation, CMS is proposing to remove some redundancies for documentation across all E/M visit levels. Specifically, CMS proposes to simplify the documentation of history and exam for established patients so that practitioners only be required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history. CMS says while practitioners would still be expected to conduct clinically relevant and medically necessary elements of history and physical exam, they would not need to re-record elements if there is evidence that the practitioner reviewed and updated the previous information. CMS also seeks information on whether it could institute similar requirements for new patients when such information is available through interoperable EHR or other means. CMS also proposes for both new and established patients, practitioners would no longer be required to re-enter information in the medical record regarding the chief complaint and history that are already entered by ancillary staff or the beneficiary. The practitioner could simply indicate in the medical record that they reviewed and verified this information. CMS states that these proposed policy changes would be optional, and a practitioner could choose to continue to use the current framework, and the more detailed information could continue to be entered, reentered or brought forward in documenting a visit, regardless of the documentation approach selected by the practitioner. New Codes for Physicians Communicating Remotely CMS is proposing new payment codes under the PFS for services that involve the use of communication technology. The first code CMS is proposing to create is code GVCI1, which would describe a virtual contact with a patient to determine whether an office visit is needed. This code would only be paid when the check-in does not result in an E/M visit within the next 24 hours or next

38 AMRPA Magazine / August 2018

available appointment, or if the check-in was not a follow-up of an E/M visit in the last seven days. If either of these scenarios are true, the virtual check-in is considered bundled in to the E/M visit and the virtual aspect will not be paid separately. CMS says the rationale for this proposal is that physicians currently have no incentive to perform a virtual check-in for patients unless it leads to an office visit, so this could avoid the more costly office-visits by incentivizing physicians to use a virtual check-in first, when appropriate. CMS is seeking comment on what types of technology should be permitted for this type of check-in, as well as whether this type of visit should also be permitted for new, non-established patients. The agency also seeks comment on whether there should be a frequency limited applied to these types of visits as well as if physicians need to obtain consent for billing this service before initiating it. The second code CMS is proposing to create is for interprofessional consultations. CMS has previously declined to pay for codes that describe interprofessional consultations, considering them bundled with other services. However, it is now reversing course and is proposing to pay for such consultations that take place using some sort of telecommunications. These codes would be billed by the consulting physician and when the patient does not need to be seen face-to-face by the consulting physician. CMS seeks comment on how to best determine the medical necessity of these types of visits and if it is possible to attribute these consultations to one Medicare beneficiary or if they could be more properly considered professional courtesy or education activities. CMS also says it has program integrity concerns about how to best ensure these codes are billed properly considering the involvement of two physicians. CMS also proposes that physicians obtain consent for the consultation from the patient before conducting the consultation, including informing the patient of any cost sharing requirements.

CMS Releases 2019 Quality Payment Program Proposed Rule; Therapists to be Included in MIPS

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

Highlights: »»

CMS proposes to require private practice physical and occupational therapists to participate in QPP in 2019.

»»

CMS seeks input on how to permit post-acute facility-based scoring for MIPS.

// CMS estimates that for 2019, 96.1 percent of MECs who participate in MIPS are expected to receive positive or neutral payment adjustments.

On July 12, the Centers for Medicare and Medicaid Services (CMS), released the proposed rule for the Quality Payment Program (QPP). The QPP, currently in its second year, is comprised of two tracks: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (AAPMs). Under the QPP, certain clinician types who meet specified eligibility thresholds are considered MIPS-eligible clinicians (MECs). A MEC will be assigned a score based on their performance in MIPS, and can have their Medicare Part B payments for the year adjusted either upwards or downwards by up to 7 percent based on that score for 2019. There are a number of important proposed changes to MIPS for next year, which are highlighted below. CMS estimates that 650,165 clinicians will be eligible and choose to participate in MIPS in 2019. For comparison, approximately 1.5 million clinicians submitted Part B claims from September 1, 2015 to August 31, 2016. A MEC can also be excluded from MIPS requirements if they participate in an AAPM. AAPMs are an alternative track to MIPS, and allow clinicians who are otherwise MECs to be exempt from MIPS and receive a five percent positive payment adjustment for successful participation in an AAPM for a payment year. This article will not focus on AAPMs, but those interested should reference the proposed rule for more information on AAPMs. CMS estimates that for 2019, 96.1 percent of MECs who participate in MIPS are expected to receive positive or neutral payment adjustments. This figure excludes the four percent of clinicians who are expected to receive a negative payment adjustment as a result of failing to report MIPS data. AMRPA’s Outpatient and Therapies Committee will be developing a response to this proposed rule.

AMRPA Magazine / August 2018 39

New Eligible Clinician Types Currently, MECs are defined as physicians, physician assistants, nurse practitioners, clinical nurse specialists or certified registered nurse anesthetists. Beginning in 2019 (payment year 2021), CMS is statutorily permitted to include additional clinician types. Accordingly CMS is proposing in this rule to include private practice physical therapists, occupational therapists, clinical social workers and clinical psychologists in MIPS in performance year (PY) 2019. CMS says it also considered proposing to add the other clinician types that are authorized by statute to be included – such as speech-language pathologists, audiologists, nurse midwives and registered dietitians or nutrition professionals – but that there would not be enough applicable MIPS quality measures for these clinician types to report. In the proposed rule, CMS acknowledged previous stakeholder comments, including comments from AMRPA, recommending that the agency take a very gradual approach to incorporating new clinician types, such as therapists, in to the MIPS program due to the complicated processes and burden inherent in the program. CMS attempts to rebut AMRPA’s concerns by pointing out that MIPS is still in a “ramp up” process, and it will be several years before it is fully implemented in terms of the full nine percent payment adjustment and the weight given to certain measures, such as cost measures. The only accommodation CMS proposes for new clinician types is to weight the Promoting Interoperability category (formerly titled “Advancing Care Information”) at zero percent of the total score for new clinician types that choose not to report those measures. It is important to note that while private practice therapists and other new clinician types are being added to MIPS, it is only clinicians that bill a sufficient threshold of Part B services or see a certain number of Part B patients that are eligible for MIPS, as discussed below. Further, only Part B services are eligible for adjustment under MIPS. Therefore, therapy or other services provided to inpatients, and not billed under Part B, are not subject to MIPS reporting requirements or payment adjustments. Low-Volume Exclusion Currently, a clinician is considered a MEC if they are one of the included clinician types, are not excluded due to participation under an AAPM, are not in their first year billing Medicare, and are not excluded due to low volume. The current low-volume exclusions states that if an otherwise eligible clinician bills $90,000 or less in a year, or treats 200 or fewer Part-B Medicare patients in a year, he or she is excluded from MIPS. However, recent legislation made two changes to the low-volume threshold definition. First, instead of basing a dollar threshold on total allowed charges, CMS is proposing to propose an exclusion if a clinician bills less than $90,000 for professional services in a year, which excludes other billable items, such as drugs. Second, CMS proposes to add a third threshold to exclude any clinician that provides 200 or less covered professional services in a year. CMS is also proposing an opt-in policy for clinicians, which was not previously available to clinicians who fell below one of the thresholds. Under this proposal, any clinician who falls below

40 AMRPA Magazine / August 2018

one or two, but not all three, of the low-volume thresholds, can choose to opt-in to MIPS. Therefore, as an example, a clinician who billed less than 200 total beneficiaries, and billed less than $90,000 in total Part B, could still choose to opt-in if they exceeded 200 total professional services for a year. Only those clinicians or groups that exceed all three of the thresholds will be required to participate in MIPS. The Four Performance Categories: Quality, Cost, Promoting Interoperability and Improvement Activities CMS proposes a number of changes to the four categories under which MECs are scored. Among other changes, it proposes to reweight the categories, as shown below. Table 50: Finalized and Proposed Weights by MIPS Performance Category and MIPS Payment Year Performance Category

Transition Year (Previously Finalized)

2020 MIPS Payment Year (Previously Finalized)

2021 MIPS Payment Year (Proposed)

Quality

60%

50%

45%

Cost

10%

15%

Improvement Activities

15%

Promoting Interoperability

25%

For the quality category, CMS is proposing to remove and 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 to remove and add a number of measures from specialty sets, which can be found in Table B in Appendix 1 of the proposed rule (pg. 36,103). Changes to the Physical Medicine Specialty set is found in Table B.14 in Appendix 1 of the proposed rule (pg. 36,205). In addition, CMS is proposing that small practices of 15 MECs or less will receive three points added on to their final Quality category score. Previously, CMS added five points to the total MIPS score but is proposing to move that bonus in to the Quality category for this year. For the Promoting Interoperability category, CMS is proposing to revise the scoring this year to reflect four objectives: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Within each objective, there would be measures to report on, some of which initially would be for bonus points only. The chart below illustrates how the scoring would work. For the Cost performance category, CMS proposes that the score will continue to be primarily determined by two metrics: the Total Per Capital Cost measure, and the Medicare Spending Per Beneficiary (MSPB) measure. In addition to continuing to use these two cost measures, CMS is proposing to add eight episode-based cost measures in 2019 (applicable to certain clinicians). These measures are displayed in the table 33.

Table 36: Proposed Scoring Methodology for the MIPS Performance Period in 2019 Objectives

Maximum Points

Measures e-Prescribing

10 Points

Bonus: Query of Prescription Drug Monitoring Program (PDMP)

5 Points bonus

Bonus: Verify Opioid Treatment Agreement

5 Points bonus

Support Electronic Referral Loops by Sending Health Information

20 Points

Support Electronic Referral Loops by Receiving and Incorporating Health Information

20 Points

Provider to Patient Exchange

Provide Patients Electronic Access to Their Health Information

40 Points

Public Health and Clinical Data Exchange

Choose two of the following: Immunization Registry Reporting Electronic Case Reporting Public Health Registry Reporting Clinical Data Registry Reporting Syndromic Surveillance Reporting

10 Points

e-Prescribing

Health Information Exhchange

Table 33: Episode-Based Measures Proposed for the 2019 MIPS Performance Period and Future Performance Periods Measure Topic

Measure Type

Elective Outpatient Percutaneous Coronary Intervention (PCI)

Procedural

Knee Arthroplasty

Procedural

Revascularzation for Lower Extremity Chronic Critical Limb Ischemia

Procedural

Routine Cataract Removal with Intraocular Lens (IOL) Implantation

Procedural

Screening/Surveillance Colonoscopy

Procedural

Intracranial Hemorrhage or Cerebral Infraction

Acute inpatient medical condition

Simple Pneumonia with Hospitalization

Acute inpatient medical condition

ST-Elevation Myocardial Infraction (STEMI) with Percutaneous Coronary Intervention (PCI)

Acute inpatient medical condition

As shown, CMS categorizes these proposed measures into two types: Procedural type and acute inpatient medical condition type. For procedural measures, the episode will be attributed to the MEC who furnished the triggering service. For the acute inpatient medical condition measures, the measure will be attributed based on E/M services rendered during the triggering hospitalization. The episode will be attributed to any MEC that delivers 30 percent or more of the E/M services during the hospitalization. For the Improvement Activities category, CMS proposes that like last year, MECs can earn points by selecting from any combination of high-weighted activities (20 points) or mediumweighted activities (10 points), for up to a total of 40 points. The minimum performance period for Improvement Activities is a continuous 90-day period, so all activities must be performed for at least 90 days. CMS is also proposing to add six new activities, modify five of the existing activities, and removing one of the activities it deems redundant. A list of the current activities and proposed changes are available in the Improvement Activities Inventory in Tables A and B of Appendix 2 of the proposed rule (pg. 36,359).

Facility-Based Scoring In last year’s rule, CMS proposed to allow “facility-based” clinicians to have the option of using their facility’s Hospital Value Based Purchasing (VBP) Program scores as a total substitute for their MIPS quality performance and cost performance scores, beginning in 2019. Under CMS’ original proposal, to qualify as a facility-based MEC and eligible to use a facility’s VBP score, a MEC must furnish 75 percent or more of services at POS codes (as used in HIPAA standard transactions) 21 (inpatient hospital) or 23 (emergency room). AMRPA responded to this policy last year by urging CMS to also 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 (often billed as 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. In this year’s proposed rule, CMS is continuing to move forward with the facility-based option for 2019, but with several changes. First, CMS is proposing that the POS code for on-campus outpatient hospital (POS code 22) also be considered facilitybased. In addition, CMS is also seeking comment, in response to stakeholder feedback like AMRPA’s, on how it could best incorporate post-acute care (PAC) facility-based clinicians in to the facility-based scoring. CMS seeks feedback on how certain clinician types contribute to the quality measures recorded by post-acute care QRPs, such as the IRF QRP. Furthermore, CMS seeks comment on which measures from each these QRPs would be most appropriate to use for facility-based scoring, and whether subsets of the QRP measures should be created. Complex Patients CMS will continue to apply a five-point bonus called the Complex Patient Bonus, which will be added on to the final, total MIPS score. This bonus is based on the Hierarchical Condition Category (HCC), which is used to evaluate risk in Medicare Advantage plans and other programs, and serves as a proxy for medical complexity. CMS will also factor in the percentage of patients treated by the clinician who are dually-eligible for Medicare and Medicaid to account for this bonus. CMS says it will continue to use the complex patient bonus until it develops more targeted ways of evaluating and compensating for patient risk and complexity. 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 2018, the threshold was set at 15 points out of the 100 possible points. This year, CMS proposes to raise the threshold to 30 points. In addition to the standard performance threshold, there is also an exceptional performance threshold. CMS has a pool of $500 million, on top of the MIPS payment adjustment, to give to exceptional performers under MIPS. In 2018, CMS set the exceptional performance threshold at 70, and is proposing to raise this threshold to 80 for 2019..

AMRPA Magazine / August 2018 41

The Rehab Partner of Choice

for Hospital Systems Across the Country. We know rehabilitation has the power to unlock the potential of our patients. So do our partners. Kindred Hospital Rehabilitation Servicesâ&#x20AC;&#x2122; clinical expertise, technology and patient engagement tools help over 150 hospital-based programs nationwide achieve operational success and the best possible patient outcomes. With forward-thinking rehabilitation and intuitive technology like our RehabTracker patient engagement app, our over 20,000 therapists help patients get back to their lives. Visit us at kindredrehab.com.

Introducing RehabTracker, our newest tool for patient engagement

Clinical Quality and Effectiveness ÂŠ 2018 Kindred Healthcare Operating, Inc. CSR 194872, EOE

42 AMRPA Magazine / August 2018

Physician Engagement

Patient Throughput Management

Regulatory Compliance

AMRPA Submits Comments Regarding CMS’ Revised Pre-Claim Review Demonstration for Home Health Services Editor’s Note: On July 30, 2018, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the revised Pre-Claim Review Demonstration for Home Health Services. The letter expresses AMRPA’s concerns regarding CMS’ approach to instituting the demonstration and the burden it will pose to beneficiaries’ access to necessary home health services and to providers’ operations. The complete letter is provided below and is available on the www.amrpa. org website.

July 30, 2018 The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 Re: Pre-Claim Review Demonstration for Home Health Services [CMS–10599] Dear Administrator Verma: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we write in response to the notice entitled Agency Information Collection Activities: Submission for OMB Review; Comment Request published by the Centers for Medicare & Medicaid Services (CMS) in the Federal Register on May 31, 2018, regarding the PreClaim Review Demonstration for Home Health Services. AMRPA is the national voluntary trade association representing more than 625 freestanding rehabilitation hospitals and rehabilitation units of general hospitals (IRH/ Us, or collectively referred to by Medicare as inpatient rehabilitation facilities (IRFs)), outpatient rehabilitation service providers, long-term care hospitals (LTCHs), and several of our members also operate home health agencies (HHAs). AMRPA members help patients maximize their health, functional ability, independence, and participation in society so they are able to return to home, work, or an active retirement. The majority of our members are Medicare participating providers and in 2016, IRH/Us served 350,000 Medicare beneficiaries with more than 391,000 stays.1 IRH/Us partner closely with HHAs in their communities to ensure that patients receive the necessary care after they leave the inpatient rehabilitation hospital setting. In 2017, 45 percent of IRH/U patients were discharged home with home health services.2 Although AMRPA supports CMS’ efforts to combat fraud, waste and abuse in the Medicare program and recognizes the positive direction of some of CMS’ proposals for the revised pre-claim review demonstration, referred to as Review Choice Demonstration (RCD), we continue to have fundamental concerns regarding the agency’s approach to instituting this demonstration. Namely, we do not support utilizing the Secretary’s demonstration authority to impose burdensome and mandatory prior authorization-like reviews upon providers based solely on their geographic location and without regard to a provider’s historic adherence to or compliance with Medicare requirements. We are concerned that CMS has decided to build upon the previous PreClaim Review (PCR) demonstration without making public any programmatic evaluation as to whether PCR actually reduced fraud, waste, and abuse in the home health sector or regarding its potential impact on beneficiary access or the quality of patient care. We urge CMS to reconsider and halt RCD, and instead invest in educating providers and developing program integrity mechanisms that selectively target truly fraudulent actors.

1. Medicare Payment Advisory Commission, Executive Summary, in Report to the Congress: Medicare Payment Policy xx (Mar. 2018). 2. eRehabData® analysis of CY 2017 Medicare beneficiaries.

AMRPA Magazine / August 2018 43

I. Fraud Reduction Potential As Congressional committees have noted, improper payment rates in the Medicare program yield little information about the program’s integrity.3 Many payment errors are attributable to faulty or incomplete documentation and it is therefore difficult to determine whether these errors represent an inappropriate loss to the Medicare trust fund or are simply “typographical errors.”4 Different types of payment errors, be it these clerical errors, or bad actors intent on defrauding Medicare, require different solutions.

on HHAs to lower expenditures in order to compensate for the increase in costs associated with participating in the demonstration. This unintended consequence could result in HHAs reducing wages, eliminating staff positions, or admitting less costly or complex patients. Not only HHAs, but upstream referring physicians and other clinicians on the care team will all be forced to divert staff time away from direct patient care and towards preparing and submitting documentation records. Hence, the demonstration appears to be wholly at odds with CMS’ stated prioritization of patients over paperwork.

Claims for home health services are often denied for insufficient documentation. Insufficient documentation is not always, or even typically, synonymous with fraudulent activity. In the highly distinct context of inpatient medical rehabilitation, for example, claims are often denied for mere technical violations of the onerous documentation requirements. With regard to home health services, our members report that recent changes to the face-to-face requirement have contributed to a lack of consistency in HHAs’ compliance with Medicare’s documentation criteria. Ultimately, requiring pre-claim or post-payment review for virtually all home health services will cause tremendous disruption to the rehabilitation and recovery of many patients while doing little to confront the conduct of bad actors willing to falsify documentation. Despite the revised demonstration’s changes, RCD would still not achieve CMS’ intended goal of reducing fraud, waste, and abuse. HHAs that are appropriately adhering to Medicare’s documentation and medical necessity requirements should not be asked to agree to a 25 percent payment penalty in order to avoid unwarranted increases in administrative burden and bureaucracy. By that same token, non-compliant agencies should not be allowed to continue their existing practices by simply opting to receive a payment reduction. AMRPA believes the demonstration constitutes an overly broad and sledgehammer approach to a problem it is not calibrated to address.

Furthermore, this demonstration effectively overrides the judgment of the clinician who is evaluating the patient first-hand and redirects the care decision-making process to the Medicare contractor staff reviewing notes in a medical record. In our members’ experience, these reviewers frequently make medical denial decisions without consideration of the beneficiary’s total condition and individual need for care. In some instances, the reviewer may not have the clinical expertise to examine the medical records and make a proper determination. It should be the professional judgment of the treating clinician to decide which combination of services is most appropriate to treat the beneficiary in accordance with Medicare coverage guidelines. RCD undermines clinician judgement and, again, does not align with the Administration’s stated goal of allowing on-the-ground clinicians to drive patients’ care.

AMRPA recommends that CMS allocate its time and resources to target specific HHAs whose behavior suggests fraudulent activity, rather than penalizing all agencies in certain states with an administratively burdensome and costly claim review or subjecting them to a 25 percent payment reduction. CMS has at its disposal alternate tools to improve program integrity, such as Targeted Probe and Educate (TPE), which works more collaboratively with providers to enhance their understanding of and compliance with Medicare’s requirements. By CMS’ estimates, it will cost the agency approximately $392.9 million to conduct claim reviews over the five-year demonstration period.5 We believe it would pay far more dividends for the federal government to invest these dollars into provider educational efforts instead of instituting another pay-and-chase method of payment recovery. II. Patients Over Paperwork AMRPA is concerned that the proposed demonstration could have unintended consequences and erode beneficiaries’ access to necessary home health services. RCD will place pressure

When patients are in acute or institutional post-acute care (PAC) settings such as IRH/Us, discharge planners and caregivers must make arrangements to transfer the patients to other – typically lower intensity – settings, including the home and community with appropriate supports. Regulatory obstacles to discharging a patient home with HHA services may force hospital providers to keep patients in the institutional setting longer. This is true for acute hospital care, post-acute hospital care, and other care settings. In the absence of timely access to home health services, hospital discharge planners may feel compelled to discharge patients to other institutional PAC settings rather than home without adequate supports. Thus, as a direct result of prior authorization-like programs for HHA, patients may end up in institutional settings, such as nursing homes, when the home and community is the most clinically appropriate setting. Keeping patients in an institutional setting for longer than is clinically appropriate creates potential health hazards for the patient as well as unnecessary stress on families, not to mention additional cost to providers, patients and ultimately payers such as Medicare. III. Program Design More broadly, AMRPA is troubled by the expanding use of the Secretary’s demonstration authority to impose sweeping mandatory policies on health care providers, especially when these policies entail extensive new regulatory burdens and harsh payment penalties for non-participation. We believe such programs are inconsistent with the spirit of testing new payment models, arguably incongruous with the agency’s statutory authority, and certainly inconsistent with Congressional intent.

3. United States. Cong. House Ways and Means Oversight Subcommittee. Efforts to Combat Wasted, Fraud, and Abuse in the Medicare Program. Hearing, July 19, 2017. 115th Cong. 2nd sess. (opening statement of Vern Buchanan, Chairman, House Ways and Means Oversight Subcommittee.) 4. Id. 5. CMS, Supporting Statement Part A Pre-Claim Review Demonstration for Home Health Services, CMS-10599/0938-1311. May 31, 2018.

44 AMRPA Magazine / August 2018

With regard to the revised elements of RCD, we appreciate that CMS has developed a target affirmation threshold for providers that demonstrate compliance. However, we recommend that CMS exempt HHAs that achieve the target affirmation rate from being required to participate for the duration of the five-year demonstration period. In addition, since provider education and awareness of these new onerous processes will be critical, we urge CMS to ensure that all affected HHAs will be adequately notified well in advance of the demonstration’s go live date.

Development (czollar@amrpa.org / 202-860-1002), or Mimi Zhang, Senior Policy and Research Analyst (mzhang@amrpa.org / 202860-1003). We appreciate your consideration of our comments.

Finally, it is important for CMS to build its demonstration programs on a solid base of evidence and understanding of the potential impact to cost savings and, most importantly, patient well-being. We recommend that CMS evaluate the results of the prior pre-claim review demonstration which took place in Illinois and make public the program’s effectiveness at reducing fraud in the home health sector, its cost to providers and to CMS, and its impact on beneficiaries’ access to care and rates of discharge to the home/community.

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

AMRPA appreciates the opportunity to comment on the Review Choice Demonstration. If you have any questions regarding our comments, please do not hesitate to contact Carolyn Zollar, Executive Vice President for Government Relations and Policy

Sincerely,

Mark J. Tarr Chair, AMRPA Regulatory and Legislative Policy Committee President and Chief Executive Officer, Encompass Health

AMRPA Magazine / August 2018 45

Study Evaluates the Effectiveness of Medicare’s Bundled Payment Program on Medical Conditions

Highlights: »»

The study found that bundled payments for five common medical conditions were not associated with lower Medicare payments or improved patient outcomes.

In 2013, the Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) Initiative to test whether bundled payments could help reduce Medicare costs while improving or maintaining beneficiaries’ quality of care. Although some studies have shown that BPCI is associated with reductions in Medicare payments for total joint replacement procedures, little is known to date about the effect of the BPCI on medical conditions. In a recent study, Evaluation of Medicare's Bundled Payments Initiative for Medical Conditions, published in the New England Journal of Medicine, researchers used Medicare claims from 2013 through 2015 to study how participating hospitals performed in BPCI for five medical conditions and compared them with matched control (non-BPCI participating) hospitals. The researchers examined the five medical conditions most commonly selected by BPCI hospitals for bundled episodes, including: 1. 2. 3. 4. 5.

46 AMRPA Magazine / August 2018

// Although some studies have shown that BPCI is associated with reductions in Medicare payments for total joint replacement procedures, little is known to date about the effect of the BPCI on medical conditions.

Congestive heart failure (CHF) Pneumonia Chronic obstructive pulmonary disease (COPD) Sepsis Acute myocardial infarction (AMI)

The researchers used difference-in-differences analyses to assess changes in standardized Medicare payments per episode of care (defined as the hospitalization plus 90 days after discharge) for these conditions at BPCI hospitals and matched control hospitals. A total of 125 hospitals participated in BPCI for CHF, 105 hospitals for pneumonia, 101 hospitals for COPD, 88 hospitals for sepsis, and 73 hospitals for AMI. At baseline, the average Medicare payment per episode of care across the five conditions at BPCI hospitals was $24,280, which decreased to $23,993 during the intervention period (difference, -$286; P=0.41). Control hospitals had an average payment for all episodes of $23,901, which decreased to $23,503 during the intervention period (difference, -$398; P=0.08; difference in differences, $112; P=0.79).

department use or readmission within 30 or 90 days after hospital discharge, or death within 30 or 90 days after admission did not differ significantly between the intervention and control hospitals. The researchers concluded that hospital participation in five common medical bundles under BPCI was not associated with significant changes in Medicare payments, clinical complexity, length of stay, ED use, hospital readmission or mortality. For the abstract, see Evaluation of Medicare's Bundled Payments Initiative for Medical Conditions, New England Journal of Medicine, 2018 July 19;379(3):260-269. doi: 10.1056/ NEJMsa1801569. The study was funded by the Commonwealth Fund.

The study found that changes from baseline to the intervention period in clinical complexity, length of stay, emergency

OMHA Case Processing Manual (OCPM) Updates The Department of Health and Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA) has, in recent months, published six new or revised chapters of the OMHA Case Processing Manual (OCPM). This manual standardizes the day-to-day procedures for carrying out adjudicative functions, in accordance with applicable statutes, regulations, and OMHA directives, and gives OMHA staff direction for processing cases at the OMHA level of adjudication for Medicare Part A and Part B initial determinations. OMHA is in the process of drafting new OCPM chapters and revising existing chapters under a new format. The following new or revised chapters have been issued since May 10, 2018: • • • • • •

Chapter 1, Manual Overview, Definition, Governance (New, effective 5-25-2018) Chapter 5, Representatives (Revised, effective 7-27-2018) Chapter 6, CMS, CMS Contractor, and Plan Roles (Revised, effective 7-27-2018) Chapter 7, Adjudication Time Frames, Case Prioritization, and Escalations (Revised, effective 7-27-2018) Chapter 19, Closing the Case (Revised, effective 5-25-2018) Chapter 20, Post-Adjudication Actions (New, effective 5-25-2018)

These new and revised OCPM chapters can be accessed on the HHS website.

AMRPA Magazine / August 2018 47

Madonna Rehabilitation Hospital Reduces Patient Falls by 21 Percent Using AHRQ’s Toolkit

Highlights: »»

The hospital saved an estimated $107,000 in medical costs by preventing patient falls.

»»

The AHRQ toolkit includes guidance on ways to build internal support for a fall prevention program.

A recent case study issued by the Agency for Healthcare Research and Quality (AHRQ) featured AMRPA member Madonna Rehabilitation Hospital and their success with reducing patient falls using an AHRQ safety toolkit. The 48-bed rehabilitation hospital in Lincoln, Nebraska, experienced a 21 percent reduction in the number of patient falls resulting in injury after implementing AHRQ’s Preventing Falls in Hospitals Toolkit in 2015. The toolkit helps hospitals overcome the challenges associated with developing, implementing, and sustaining a fall prevention program. According to Jackie Krason, R.N., M.S.N., Madonna’s Quality and Risk Management Supervisor, the hospital prevented eight patient falls during a nearly two-year period, with an estimated savings of $107,000 in medical costs. Using the toolkit, the hospital updated its fall risk assessment system to use more specific risk factors, which was instrumental in enabling nurses to better identify those patients at greatest risk of a fall. “We developed and tested a new system that could accurately assess the impact that cognition, history of falls, gait and balance had on a post-acute care patient’s risk of falling,” Krason said. “We previously had a fall prevention program in place, but it was definition-driven instead of risk-driven.” Fall prevention involves managing a patient's underlying fall risk factors and optimizing a hospital's physical design and environment. The AHRQ toolkit includes guidance on ways to build internal support for a fall prevention program. Staff education is also emphasized in the toolkit, which led the hospital to provide annual, mandatory training for all employees. The in-person training, which includes an online component with follow-up tests as well as hands-on competency, is tied to an employee’s annual performance evaluation. Surveillance of the physical environment is also important, noted Terasa Farlin, R.N., the hospital’s nurse manager. “With our facility’s increased focus on preventing falls, nursing staff and therapists now conduct an assessment of the condition of each patient’s room during their hourly rounds. This presents the opportunity to relocate unneeded equipment or electrical cords that could pose a hazard.” Madonna Rehabilitation Hospital was one of several providers recruited to participate in a project that evaluated the effectiveness of AHRQ’s Preventing Falls in Hospitals Toolkit. The toolkit is available here. For the case study, see “AHRQ Toolkit Helped Madonna Rehabilitation Hospital Reduce Patient Falls by 21 Percent” July 2018, Patient Safety, Impact Case Study, AHRQ.

48 AMRPA Magazine / August 2018

We donâ&#x20AC;&#x2122;t just move you forward, W E L I F T Y O U U P. Mary Free Bed Rehabilitation Hospital restores hope and freedom for patients who have experienced traumatic, life-changing injuries. The 167-bed, non-profit, freestanding hospital is a national leader in rehabilitation.

To make a referral, call 616.840.8790 maryfreebed.com | 235 Wealthy St. SE | Grand Rapids, MI 49503 AMRPA Magazine / August 2018 49

FY 2019 IPPS/LTCH Final Rule Released: LTCHs Will Be Permitted to Operate IRF Units By Jonathan Gold, JD, Regulatory and Government Relations Counsel, AMRPA On August 2, the Centers for Medicare and Medicaid Services (CMS) released its Inpatient Prospective Payment System and Long-Term Care Hospital (IPPS/LTCH) final rule for federal fiscal year (FY) 2019. Most notably in this final rule, CMS finalized its proposal to permit IPPS-excluded hospitals to operate IPPS-excluded units, effective October 1, 2019 (FY 2020). Among other combinations, this means that an LTCH will now be permitted to operate an inpatient rehabilitation facility (IRF) unit. In addition, freestanding IRFs will be permitted to operate psychiatric units. However, CMS notes in this rule that all other Medicare Conditions of Participation (CoPs) for each hospital type will continue to apply, so, for example, IRFs would need to meet any CoPs specific to psychiatric units if it chose to operate a unit. In addition to the change to excluded-unit locations, in this final rule CMS finalized its proposal to require all hospitals to post online standard inpatient charges, and to update the information annually. In addition, for LTCHs, CMS permanently repealed the “25 percent rule” which reduced an LTCH’s reimbursements if more than 25 percent of its patient referrals came from a specific acute care hospital. . Further, as part of its Meaningful Measures initiative, CMS removed a number of quality measures from the Inpatient Hospital Quality Reporting (IQRP) Program and Hospital Value-Based Purchasing (VBP) program. CMS also reduced the number of measures for the Electronic Health Record Meaningful Use program for acute-care hospitals.

JOIN TODAY!

EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE

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

50 AMRPA Magazine / August 2018

Mobile Tablet-Based Therapy Following Stroke

Highlights: »»

The study found that stroke patients are interested in mobile tabletbased therapy, and that it should be initiated earlier in the post-stroke period.

Mobile tablet technologies may facilitate rehabilitation interventions during the early hospitalization period following acute stroke, according to a recent study published in the International Journal of Stroke. A group of researchers sought to gain a better understanding of stroke patients’ experiences and recovery goals following use of a mobile tablet-based post-stroke communication therapy tool during their acute care hospital stay. Prior research had found that patients with stroke are often inactive and alone during their acute care hospitalization: in the 14-day period following a stroke, patients spend over 50 percent of their time resting in bed, and 60 percent of their time alone.1 This acute care “downtime” provides an opportunity for targeted rehabilitation interventions using mobile platform technologies that can be utilized in wardrooms without supervision or additional health care personnel.

// A group of researchers sought to gain a better understanding of stroke patients’ experiences and recovery goals following use of a mobile tabletbased post-stroke communication therapy tool during their acute care hospital stay.

In the study, speech-language pathologists (SLPs) or occupational therapists (OTs) identified patients with stroke and communication, fine motor, or cognitive/perceptual deficits. Patients were provided with iPads individually programmed with applications based on their own assessment results, and were instructed to use it at least one hour per day. At discharge, patients completed a 19-question quantitative and open-ended engagement survey addressing intervention timing, mobile device/apps, recovery goals, and therapy duration. The researchers enrolled 33 participants (three did not complete the survey) over a six-month period. Median time from stroke to initiation of tablet-based therapy was six days. Patients engaged in therapy on average 59.6 minutes a day, and preferred communication and hand function therapies. Most patients (63.3 percent) agreed that therapy was commenced at a reasonable time, although half expressed an interest

AMRPA Magazine / August 2018 51

in starting sooner; 66.7 percent reported that using the device one hour per day was enough; 64.3 percent would use it after discharge; and 60.7 percent would use it for eight weeks. 67 percent of patients expressed a need for family/friend/caregiver to help them use it. These results and previous studies suggest that stroke patients are interested in mobile tablet-based therapy, and that these therapies could be initiated earlier in the post-stroke period. The study found that patients in the acute setting prefer to focus on communication and hand therapies and are willing to begin this type of intervention within days of their stroke.

52 AMRPA Magazine / August 2018

For the abstract, see the International Journal of Stroke, 2018 Jan 1:1747493018790031. doi: 10.1177/1747493018790031. RecoverNow: A patient perspective on the delivery of mobile tablet-based stroke rehabilitation in the acute care setting. Note 1. Bernhardt J, Dewey H, Thrift A, Donnan G. Inactive and alone: physical activity within the first 14 days of acute stroke unit care. Stroke. 2004;35:1005â&#x20AC;&#x201C;9. doi: 10.1161/01.STR.0000120727.40792.40

Latest Research Findings

Researchers Examine Medicare’s Inpatient Rehabilitation Discharge Self-Care Functional Status Quality Measure Pursuant to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, the Centers for Medicare and Medicaid Services (CMS) introduced in 2016 four outcomesbased functional status quality measures into the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) for mandatory reporting. The measures are:

A recent article authored by the measure developers, including CMS and RTI International, takes a closer look at the psychometric properties of the discharge self-care functional status measure (NQF #2635). The measure has been reported by all Medicareenrolled inpatient rehabilitation providers since October 2016. The

Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients (National Quality Forum (NQF) measure #2633); IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634); IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635); and IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636).

AMRPA Magazine / August 2018 53

article’s analysis, however, is based on a smaller dataset collected under the Post-Acute Care Payment Reform Demonstration (PAC PRD) between 2008 and 2010. The cohort study included Medicare fee-for-service (FFS) patients aged 21 years and over from 38 IRFs that participated in the CMS Post-Acute Care Payment Reform Demonstration (PAC-PRD). Data was taken from the Continuity Assessment Record and Evaluation (CARE) Item Set, Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI), and Medicare claims. For each patient, the researchers calculated an expected discharge selfcare score, risk-adjusted for demographic and baseline clinical characteristics. The performance score of each IRF equaled the percentage of patient stays where the observed discharge selfcare score met or exceeded the expected score. The researchers then assessed the measure's discriminatory ability across IRFs and reliability. A total of 4,769 patient stays were included; 57 percent of stays were women, and 12.1 percent were patients aged 65 years and

older. Stroke was the most common diagnosis (21.8 percent). The mean ± SD performance score was 55.1 percent ± 16.6 percent (range, 25.8 percent–100 percent). Roughly 54 percent of IRFs had scores significantly different from the percentage of stays that met or exceeded the expected discharge self-care score in the overall demonstration sample. The quality measure showed strong reliability, with intraclass correlation coefficients of 0.91. According to the study authors, the discharge self-care quality measure showed strong discriminatory ability and reliability, and a wide range in performance scores suggested a gap in quality of care across providers included in the PAC PRD dataset. The authors suggest testing the measure with nationwide data from all inpatient rehabilitation providers in the future. Source: “Measuring Inpatient Rehabilitation Facility Quality of Care: Discharge Self-Care Functional Status Quality Measure”, Abstract Archives of Physical Medicine and Rehabilitation, June 2018, Volume 99, Issue 6, Pages 1035–1041.

Study Evaluates Hospital Readmission Rates After Discharge From Inpatient Rehabilitation A recent study examined facility-level rates of all-cause, unplanned hospital readmissions for 30 days after discharge from inpatient rehabilitation hospitals and units (IRH/Us). As study authors, CMS staff partnered with researchers from RTI International and the Rehabilitation Institute of Chicago (RIC) to evaluate the “All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from

IRFs.” The measures was a mandatory measure in the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) until its removal in October 2017. The study sample included Medicare fee-for-service beneficiaries (N=567,850 patient-stays) who used inpatient rehabilitation services and were discharged from IRFs in 2013 and 2014. Adapting existing risk-adjustment and statistical approaches used for acute care hospitals, the authors developed a hierarchical logistic regression model that estimates a risk-standardized readmission rate for each rehabilitation hospital. The IRF risk-adjustment model takes into account patient demographic characteristics, hospital diagnoses and procedure codes, function at IRF admission, comorbidities, and prior hospital utilization. The study also presents national distributions of observed and risk-standardized readmission rates and estimated confidence intervals to make statistical comparisons relative to the national mean. The study found that the national observed all-cause hospital readmission

54 AMRPA Magazine / August 2018

rate 30 days post-discharge from IRFs was 13.1 percent, based on 2013-2014 data. The mean unadjusted readmission rate for IRFs was 12.4 percent ± 3.5 percent, and the mean risk-standardized readmission rate was 13.1 percent ± 0.8 percent. The C-statistic for the risk-adjustment model was 0.70. Approximately three-quarters of IRFs (73.4 percent) had readmission rates that were significantly different from the mean. The mean number of days to from IRF discharge to hospital readmission was 13.0±8.6 days and varied by rehabilitation diagnosis.

According to the authors, the study demonstrated the ability to assess 30-day, all-cause hospital readmission rates post-discharge from IRFs and the ability to discriminate between IRFs with higherand lower-than-average hospital readmission rates. Source: “Evaluating Hospital Readmission Rates After Discharge From Inpatient Rehabilitation”, Abstract Archives of Physical Medicine and Rehabilitation, June 2018, Volume 99, Issue 6, Pages 1049–1059.

Association Between Functional Status at IRF Discharge and Potentially Preventable Hospital Readmissions The IMPACT Act requires CMS to develop and implement standardized quality and resource use measures, such as readmissions, for post-acute care settings. Under this mandate, CMS has adopted a readmissions measure for the IRF QRP that assesses “potentially preventable” readmissions for 30 days following patients’ discharge from IRFs. A retrospective cohort study sought to determine the association between patients’ functional status at IRF discharge and 30-day potentially preventable hospital readmissions, and also to examine the conditions resulting in these potentially preventable readmissions. The study included a national cohort (N=371,846) of inpatient rehabilitation discharges among aged Medicare fee-for-service beneficiaries in 2013 to 2014. The average age was 79.1±7.6 years. Most were women (59.7 percent) and white (84.5 percent).

The study concluded that functional status at discharge from inpatient rehabilitation was associated with 30-day potentially preventable readmissions in the sample of aged Medicare beneficiaries. While this information may help identify at-risk patients, the study states that future research is needed to determine whether follow-up programs focused on improving functional independence will reduce readmission rates. Source: “Functional Status Is Associated With 30-Day Potentially Preventable Hospital Readmissions After Inpatient Rehabilitation Among Aged Medicare Fee-for-Service Beneficiaries”, Abstract Archives of Physical Medicine and Rehabilitation, June 2018, Volume 99, Issue 6, Pages 1067–1076.

The study found that the overall rate of potentially preventable readmissions after inpatient rehabilitation was 5.0 percent (n=18,477), and the overall rate of any 30-day hospital readmission was 12.4 percent (n=46,265). Functional independence was associated with lower observed rates and adjusted odds ratios for potentially preventable readmissions. Observed rates for the highest versus lowest quartiles within each functional domain were as follows: self-care: 3.4 percent (95 percent confidence interval [CI], 3.3–3.5) versus 6.9 percent (95 percent CI, 6.7–7.1), mobility: 3.3 percent (95 percent CI, 3.2–3.4) versus 7.2 percent (95 percent CI, 7.0–7.4), and cognition: 3.5 percent (95 percent CI, 3.4–3.6) versus 6.2 percent (95 percent CI, 6.0–6.4), respectively. Similarly, adjusted odds ratios were as follows: self-care: .70 (95 percent CI, .67–.74), mobility: .64 (95 percent CI, .61–.68), and cognition: .84 (95 percent CI, .80–.89). Infection-related conditions were the most common readmission diagnoses (44.1 percent), followed by inadequate management of chronic conditions (31.2 percent) and inadequate management of other unplanned events (24.7 percent).

AMRPA Magazine / August 2018 55

As part of AMRPA’s efforts to ensure our members remain active in shaping their federal representation in Congress, we are continuing to provide updates on Congressional elections. Below you’ll find information on primaries taking place in September and November, as well as online resources where you can find additional information on voting, Congressional representatives, and primary election results.

Be sure to visit the AMRPA Congressional Elections webpage for more information and primary election results: www.amrpa.org/Advocacy/2018-Congressional-Elections. If you have any questions or feedback, contact Catherine Beal at cbeal@amrpa.org or 202-860-1006.

The following states will be holding primary elections in September, for a total of five primary elections:

Massachusetts – September 4, 2018

Find your House representative here: www.house.gov/ representatives/find-your-representative and Senators here: www.senate.gov/general/contact_information/senators_ cfm.cfm.

Nine House seats are up for election: eight incumbents and one open seat. One Senate seat is up for election.

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

Delaware – September 6, 2018 One House seat is up for election. The incumbent is running for reelection. One Senate seat is up for election.

New Hampshire – September 11, 2018 Two House seats are in the delegation: one incumbent and one open seat. No Senate seats are on the ballot.

Rhode Island – September 12, 2018 Two House seats are up for election. Both incumbents are running for reelection. One Senate seat is up for election.

New York – September 13, 2018 New York has 27 House seats on the ballot: 26 incumbents and one open seat. One Senate seat is up for election.

56 AMRPA Magazine / August 2018

For more information on your federal representatives, visit the following websites:

Edward A. Eckenhoff Memorial Award & Lecture Series Honoring one of the Founding Fathers of AMRPA

“The Future of Medical Rehabilitation: Lessons from the Past” With Dr. John L. Melvin, MD, MM 10:30 AM –11:15 AM Tuesday, September 25, 2018 Experience AMRPA’s new annual plenary session that honors one of the Association’s founding fathers and a visionary leader in the rehabilitation field: Edward Eckenhoff. Dr. John Melvin has presented more than 450 invited lectures throughout the world and published more than 230 papers, chapters, monographs, books, editorials and abstracts. He has been active in the development of programs for individuals with physical disabilities for many years, and will share his insights into administration, management, research, education and patient care Tuesday morning of the conference!

2018

Fall Educational Conference & Expo September 24-26, 2018 Boston Park Plaza • Boston, MA #AMRPA

www.amrpa.org/register

AMRPA Magazine / August 2018 57

Turning the force of gravity into a force for good. Empowering patients through their rehabilitation starts with making the process easier. The Talem Maestro Clinical is a mobile dual arm support system that helps patients stay engaged and enthusiastic in their rehab program by reducing the pull of gravity. This allows patients with neuromuscular injuries and diseases to do more reps with more power, allowing them to regain their independence faster. Maestro Clinical comes with an adjustable rolling workstation for flexibility and versatile treatment in any size lab. Once itâ&#x20AC;&#x2122;s installed, youâ&#x20AC;&#x2122;ll see that it only takes a little extra help to unleash the strength inside.

To see how defying gravity is the starting point to recovery, visit talem.com/clinical or see us at the AMRPA Expo.

ADVERTISING RATES:

ADVERTISING CONTACT:

Full page - $1500 Half page - $1000 Third page - $750 Ads may be B&W or full color.

Samantha Schwarz Phone: +1-202-207-1132 Email: sschwarz@amrpa.org

ADVERTISE IN OUR MAGAZINE

DISCOUNTS FOR MEMBERS

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. 60 AMRPA Magazine / August 2018