September 2019 • Vol. 22, No.9
2019
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September 2019 • Vol. 22, No. 9
The official publication of the American Medical Rehabilitation Providers Association (AMRPA) Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Director Kate Beller, JD AMRPA Executive Vice President for Government Relations and Policy Development Carolyn Zollar, MA, JD AMRPA Senior Policy Counsel Mimi Zhang AMRPA Director of Payment Innovation, Quality and Research Patricia Sullivan AMRPA Senior Editor Brian McGowan Design and Layout
AMRPA Magazine, Volume 22, 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.
Table of Contents Letter from the Chair
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Legislative Update
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CMS Issues Proposed Rule on DMEPOS Impacting Rehabilitation Patients, Providers and Innovators
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Rehabilitation Hospitals Encouraged to Comment on CMS’s Proposed Hospital Transparency Requirements
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Staff Education and Testing for QRP Changes
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CMS Finalizes FY 2020 IRF PPS Rule
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MedPAC Issues 2019 Data Book on Medicare Utilization and Spending Trends
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CMS Releases 2020 Physician Fee Schedule Proposed Rule
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Don’t Miss Out on a Full Day of Education and Mentorship at AMRPA’s IRF Boot Camp!
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AMRPA Successfully Relaunches Regional Meetings Series
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Study Examines Relationship Between Hospital-based Rehabilitation Services and Hospital Readmission Following Ischemic Stroke
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HHS OIG Publishes Report Examining Accountable Care Organizations’ Strategies for Transitioning to Value-Based Care
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SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color. Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Julia Scott, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1110, Email: jscott@amrpa.org. Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content ©2019 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Kellen Company. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 750, Washington, DC 20045
AMRPA Magazine / September 2019
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Letter from the Chair
Richard Kathrins, PhD, President & CEO, Bacharach Institute for Rehabilitation RKathrins@bacharach.org
Who Benefits? An AMRPA member recently told me that they continue to see a shift in patients out of institutional post-acute care, driven mainly by a wish to avoid costs. The conversation occurred in conjunction with the release of an article in the New England Journal of Medicine titled, “Postacute Care – The Piggy Bank for Savings in Alternative Payment Models?” (Barnett, Mehrotra, & Grabowski, 2019). The shift within post-acute care is becoming widely recognized. The article by Bernett et al. (2019) raises some key points for AMRPA members: Value-based payment models motivate hospitals to discharge some patients to their homes instead of to an appropriate post-acute care setting, as the authors specifically found that “hospitals may begin to send home patients who need institutional rehabilitation (p. 302).” The authors also stated that, “[m]oreover, few evaluations have assessed the effect of payment reforms on patients’ functional status or experience (p. 303).”
Thus far, value-based programs have not “resulted in substantial reductions in patient satisfaction or worsening outcomes. But the absence of clear problems several years into these programs provides only minimal reassurance (p. 302-3).”
Hospitals may cross-subsidize losses of lower-profit margin cases (such as Medicaid)
with privately insured populations, as do skilled nursing facilities. The shift away from institutional post-acute care created an unintended consequence on the post-acute care world in that some facilities have been forced to downsize or even close due to lower than anticipated volume and/or inability to cover losses due to the decline in their Medicare admissions.
Finally, sending more patients home may place more strain on families and their communities to assist with activities of daily living and other needs.
The authors concluded that, “…under alternative payment models, hospitals gain and SNFs lose when healthier patients go directly home from the hospital (p. 303).” In addition, given the "important role” post-acute care has played in health reform, the authors state that “policymakers… should pay attention to the effects of changes in post-acute care on patients, families and the market more broadly (p. 303).” Post-acute care is also being impacted by Medicare’s Comprehensive Joint Replacement (CJR) Program. A recent report on the CJR Program and its effect on Medicare beneficiaries noted, “While CJR appears to be successfully reducing the use and cost of facility-based post-acute rehabilitation, there are few findings on how Medicare beneficiaries fare in their recoveries under CJR in terms of their everyday physical activities...(Medicare’s Comprehensive Joint, para 1). ” The report also stated it was unclear how beneficiaries integrated into the community. Consistent with my member interaction, these writings affirm what we as post-acute providers know experientially – that post-acute care decisions in value-based payment reforms are being financially driven when they should be patient-driven. We need to speak to this issue and push for a metric that measures value not only in terms of short-term cost. Value should be defined as a function of outcomes per unit of cost. But, in addition to measuring costs or spending, policies attempting to increase value must measure the right outcomes for patients – these include meaningful outcomes function measures and longerterm patient well-being beyond the typical 90-day window used in most APMs we see today, just to start. Value-based programs should improve the care for the individual, improve health for the population, and spend less or at least no more for equivalent or improved outcomes. Our Association will continue to push for meaningful reforms that are based on these objectives.
Bennett, M.L., Mehrotra, M., & Grabowski, D.C. (2019, July 25). Postacute care- the piggy bank for savings sin alternate payment. New England Journal of Medicine, 381 (4), 302-3. Medicare’s comprehensive joint replacement program: How are Medicare beneficiaries benefitting? (n.d.). Retrieved from http://www.njha.com/healthy-communities/understanding-the- healthcare-landscape/chart/2019/may/introduction/ 4
AMRPA Magazine / September 2019
Find new and exciting opportunities in AMRPA’s Career Center. Our newly updated Career Center provides services and resources to help the medical rehabilitation field meet their professional goals. All rehabilitation professionals may browse and apply for jobs at no cost, and AMRPA members will receive discounted rates for posting positions.
Visit our Career Center Here:
careercenter.amrpa.org
Begin by creating your free Career Cast account, which can be found on the top right hand corner of the website. From there, you can upload and manage multiple resumes, browse through hundreds of job postings, and even research salaries of the positions in question! AMRPA members and affiliates may also purchase Posting Packages at a standard, premium, or platinum level. AMRPA members will receive a 50% discount on all job postings. For questions about our Career Center, contact Anna Kruskop, AMRPA Member Services Associate, at akruskop@amrpa.org or 202-207-1120.
AMRPA Magazine / September 2019
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Legislative Update
Martha M. Kendrick, Esq., Partner, Akin Gump Strauss Hauer & Feld LLP
Highlights: »»
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ongressional leadership and the Trump C administration reach agreement on how to raise the Budget caps and set federal spending limits for two years, ending the threat of automatic spending cuts that would have taken effect in January 2020. The House and Senate must pass all 12 FY 2020 Appropriations bills and get them to the president’s desk by September 30 in order to avoid a government shutdown. Surprise billing and prescription drug legislation will dominate the policy agenda in the fall. CMS proposes major hospital transparency requirements in annual payment regulation.
Congress and the White House Agree to Budget Cap Deal The House recessed on July 25 after voting 284-194 to pass a $2.7 trillion, two-year budget deal (H.R. 3877) that suspends the debt ceiling through July 2021 and raises total spending by $100 billion over current levels for FY 2020 and FY 2021. The Senate remained in session an additional week, and on August 1 officially cleared the package by a vote of 67-28. President Trump quickly signed the budget deal into law. In order to pay for the spending package, Medicare sequestration is extended through 2029, along with an extension of customs user fees. The Congressional Budget Office (CBO) estimated that H.R. 3877 will increase spending around 2% for Medicare benefits through September 2027, but reduce spending by 2% from October 2027 through March 2029, and by 4% from April 2029 through September 2029. The agreement included language that aims to effectively block “poison pill” riders in the Appropriations bills. The two political parties have put their own spin on the policy, with Democrats claiming that the agreement maintains the status quo in which a bipartisan agreement from the four Congressional leaders and the White House is required to insert a “rider” into an Appropriations bill, while Republicans tend to assert that the language blocks all poison pill policies. The House has passed the majority of its FY 2020 Appropriations bills, except for Homeland Security and Legislative Branch, due to controversial policy issues, such as immigration and increasing members’ salaries. The Senate has yet to begin its process, but with the new Budget deal providing specific spending limits, the chamber will likely consider its Appropriations bills in early September. Senators will be focused on developing and passing bipartisan spending bills before funding for the federal government runs out at the end of the 2019 fiscal year on September 30. Lawmakers return from the August recess after Labor Day, giving them only 13 days to come to a bipartisan, bicameral agreement to clear all 12 Appropriations bills or pass a Continuing Resolution (CR). It is expected that several of the bills may be packaged together and passed, but a larger, more comprehensive Omnibus package is also not out of the question. Post-August Recess Outlook Recent months have seen a flurry of activity in Congress on prescription drug pricing and surprise medical bills as lawmakers seek to address rising consumer health care costs. Several House and Senate committees advanced legislation on drug pricing and surprise billing, and additional activity is expected in September following the August recess, including possible floor action. The Lower Health Care Costs Act (S. 1895) reported out of the Senate HELP Committee contains a number of surprise billing provisions, many of which remain controversial with members. Like other surprise billing measures, S. 1895 holds patients harmless in outof-network emergency care situations and for care provided by ancillary out-of-network practitioners at in-network facilities. The bill adopts a benchmark payment rate approach
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with respect to determining reimbursement for providers in these scenarios. Specifically, providers would be paid the median innetwork rate based on their geographic area. The surprise billing provisions would also apply to air ambulance services. Senators on both sides of the aisle have raised concerns about the benchmark payment approach, which is seen as favoring insurers. Sen. Bill Cassidy (R-LA) and a bipartisan group of senators had previously released their own proposal, the STOP Surprise Medical Bills Act (S. 1531), which relies on a “baseball-style” arbitration process to resolve payment disputes. HELP Committee Chair Lamar Alexander (R-TN) has signaled he is open to making changes to the payment methodology before the bill moves to the Senate floor. The House Energy and Commerce Committee advanced its own surprise billing legislation, the No Surprises Act, on July 17. Like the Senate HELP bill, the No Surprises Act holds patients harmless for out-of-network emergency care and in situations where they cannot reasonably choose a provider. The bill includes some reporting requirements for air ambulance providers and suppliers but does not apply the surprise billing provisions to this sector. The No Surprises Act initially utilized a benchmark payment approach based on the median in-network rate. In response to concerns from several members, however, the Committee adopted an amendment from Reps. Raul Ruiz (D-CA) and Larry Bucshon (RIN) to add an independent dispute resolution (IDR) process as a backstop to the benchmark approach. Senate leaders are holding to their plan to combine surprise billing and drug pricing legislation into one package before floor consideration. While there is wide bipartisan support for action on surprise billing, a number of members have raised objections with the HELP Committee’s package. Senate Republican leadership recently “hotlined” the bill in order to gauge support, finding that more than a dozen Republicans were prepared to place “holds” on the bill due to concerns over the payment methodology in the legislation. In particular, several senators are pushing HELP Chair Alexander to add an arbitration component to the bill. Alexander, for his part, said he was optimistic that the holdout Republicans would still support the package if it were put to a floor vote. Of course, even if the Lower Health Care Costs Act passes the Senate as-is, it would need to be reconciled with House legislation. Meanwhile, the House Education and Labor Committee is expected to mark up the No Surprises Act, though timing for such a markup has not been announced. The House Ways and Means Committee has yet to release its own surprise billing proposal, but Committee Leadership has indicated it is taking steps to find a solution to protect patients from surprise bills. It is safe to expect a very active fall as House and Senate leadership attempt to find a path forward on drug pricing and surprise billing. During the August recess, groups on all sides of these debates will be taking their arguments to their members back home. Also lurking in the background are potential court decisions around the Affordable Care Act and a possible Administration plan to replace the health law.
Medicare Payment Rules Proposed On July 29, the Centers for Medicare and Medicaid Services (CMS) released the Medicare Physician Fee Schedule (PFS) Updates for Calendar Year (CY) 2020, as well as the CY 2020 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Proposed Rules. In the Physician Fee Schedule Proposed Rule CMS proposes to establish modifiers to identify services provided “in whole or in part” by physical therapy (PT) and occupational therapy (OT) assistants, and set a de minimis 10% standard for when these modifiers will apply to specific services beginning on January 1, 2020. CMS proposes to abandon its plan to implement a single/blended payment rate for certain evaluation and management (E/M) office visits for CY 2021. Instead, CMS proposes to align changes to E/M payment and coding with recommendations from the American Medical Association (AMA) CPT Editorial Panel, which CMS expects will increase payment for these services. The agency would slightly increase the conversion factor from $35.04 to $36.09 in CY 2020. CMS also proposes changes to coding and payment for chronic care management (CCM) services, including: Replacing certain codes with Medicare-specific codes to allow clinicians to bill in 20-minute increments to reflect additional time and resources; and creating new coding for principal care management (PCM) services, which would pay clinicians for providing care management to patients with a single serious and high-risk condition. The agency proposes to allow physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified nurse-midwives to review and verify medical record notes entered by other clinicians, without re-documenting notes, as is currently required. CMS also seeks comment on several policies, including opportunities to utilize bundling, such as how it is used in the Center for Medicare and Medicaid Innovation Oncology Care Model, to recognize efficiencies, achieve better care for patients, and lower costs. Within the proposal for the Quality Payment Program (QPP) CMS does not propose to make other clinician types eligible for MIPS in 2020 or future years, specifically noting clinical social workers. Further, CMS does not accept AMRPA’s efforts to include IRH/Us (and the IRF QRP) in the facility-based scoring option by proposing not to add any other facility types to the program but suggests it will reconsider in the future. The Hospital Outpatient Prospective Payment rule contains a proposal to require hospitals to post their standard charges— including both gross charges and payer-specific negotiated charges—for all items and services online in a machine-readable file. Additionally, the Proposed Rule would require hospitals to post online a consumer-friendly display of payer-specific negotiated charges for certain “shoppable” services (i.e., non-urgent health care services that consumers can schedule in advance). Comments are due on the regulations on September 27, 2019. CMS Finalizes Hospice Payment Update for FY 2020 On July 31, CMS released the FY 2020 Hospice Wage Index and Payment Rate Update Final Rule. Hospice payment rates will be updated by 2.6% ($520 million increase in their payments) in FY 2020. CMS finalized changes to the hospice election statement,
AMRPA Magazine / September 2019
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which requires hospices to provide Medicare beneficiaries, contractors, and providers with a list of (and rationale for) items, drugs, and services providers believe are not related to a beneficiaries’ terminal illnesses. This policy change is supported by the Medicare Payment Advisory Commission (MedPAC) and most commenters, according to the agency. CMS continues to work on a real-time patient assessment tool. House Ways and Means Committee Leaders Request CMS Action on Hospice Oversight House Ways and Means Committee Chair Richard Neal (DMA) and Ranking Member Kevin Brady (R-TX) sent a letter to CMS inquiring how the agency plans to increase its oversight of hospices, as recommended in a recent report by the HHS Office of Inspector General (OIG), as well as collect better quality information. OIG found that over 80% of hospices providing care between 2012 and 2016 were operating with at least one deficiency, such as poor care management, inadequate aide training, and lack of enforcement tools. More than half of hospices had multiple deficiencies. The Committee leaders are also interested in CMS’ plans to resolve patterns of abuse and neglect in the hospice sector and requested information on the quality measures CMS plans to use to improve quality reporting. They asked the agency to respond within two weeks.
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*** We hope you are using the August Congressional Recess to reach out to your members of Congress to alert and educate them on the negative impact of prior authorization for inpatient rehabilitation services and urge Congress to reform the prior authorization program in Medicare. Members of Congress need to be educated about the adverse impact of the use of prior authorization in the Medicare Advantage (MA) program, and the care delays and patient access issues that such policy presents certain types of providers, including inpatient rehabilitation hospitals and units. We would be pleased to discuss the topics and assist you with materials for any meetings you set up. If you cannot meet with your members this month, please look forward! Despite what is expected to be a very busy month for Congress, members will recess again in late September through October 13. If you have not yet, please activate grassroots advocacy on behalf of the field! You can meet your Representative at their local district offices or, better yet, invite them to visit your hospitals. Congress is on the brink of making several significant health care policy decisions as major legislative packages come together this fall. We would be happy to provide you with any additional information and assistance you may need in reaching out to your members of Congress. Please be in touch if you need any assistance! In this still-new Congress, we greatly appreciate your time and willingness to help AMRPA build relationships and educate members of Congress about key issues of concern to the field.
2019 AMRPA Schedule of Events CONFERENCE DATES 2019 Fall Educational Conference & Expo in San Diego Sunday, October 13, 2019: IRF Boot Camp October 14-16, 2019: Fall Conference & Expo REGISTRATION NOW OPEN! AMRPA WEBINARS Thursday, September 12, Noon ET Considerations for Adolescents on Adult Inpatient Rehabilitation Units Presented by Sue Harlow, OTD, OT/L AMRPA MEMBERS ONLY CALLS Wednesday, October 23 at 1:00 p.m. ET Wednesday, December 18 at 1:00 p.m. ET eRehabData® WEBINARS: AVAILABLE TO eRehabData® SUBSCRIBERS ONLY Visit eRehabData.com for more Information.
Please visit www.amrpa.org for registration information.
AMRPA Magazine / September 2019
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CMS Issues Proposed Rule on DMEPOS Impacting Rehabilitation Patients, Providers and Innovators
Peter W. Thomas, JD, Principal, The Powers Law Firm
Christina Hughes, JD, MPH, AMRPA counsel, the Powers Law Firm
Joseph Nahra, Manager of Government Affairs, the Powers Law Firm
On July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule containing updates to the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) regulations. (The rule also includes updates to CMS’ payment system for end-stage renal disease.) The rule includes a number of provisions that impact DMEPOS items and services relied on by rehabilitation patients after they leave post-acute care settings such as inpatient rehabilitation hospitals and units (IRFs). The most significant proposals involve a new process for calculating payment amounts for new items and services (“gap-filling”) and a new consolidated list of DMEPOS that is eligible for prior authorization. Comments on the proposed rule are due on September 27, 2019. AMRPA expects to join other members of the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition to submit comments on behalf of Medicare beneficiaries and the providers who serve them. The proposed rule’s provisions are not expected to have any direct impact on IRF providers or patients while in inpatient care. However, given the anticipated needs of many IRF patients with respect to DMEPOS post-discharge, this topic remains relevant to IRFs, especially with respect to the requirements for written orders/prescriptions since those may be generated as part of the discharge planning process. AMRPA has traditionally advocated strongly on behalf of its patient population. For these reasons, we summarize the key proposals below and bring them to the attention of the AMRPA membership. New Methodologies for Determining Pricing for DMEPOS Subject to Coding Changes CMS is proposing to add a provision to the regulations (at §414.236) that addresses the continuity of pricing when items are re-designated from one HCPCS code to another. CMS is proposing that if a new code is added, CMS or its contractors would determine whether the item and service has a fee schedule pricing history. If there is a fee schedule pricing history, the previous fee schedule amounts for older but similar codes would be associated with, or “cross walked” to the new code(s), to ensure continuity of pricing. CMS provides the following examples in the proposed rule: When the code for an item is divided into several codes for the components of that item, the total of the separate fee schedule amounts established for the components would not be higher than the fee schedule amount for the original item. When there is a single code that describes two or more distinct complete items (for example, two different but related or similar items), and separate codes are subsequently established for each item, the fee schedule amounts for the new
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code would be established by adding the fee schedule amounts used for the components. When the codes for several different items are combined into a single code, the fee schedule amounts for the new code would be established using the average (arithmetic mean), weighted by allowed services, of the fee schedule amounts for the formerly separate code. Gap-Filling for New DMEPOS Items Last year’s DMEPOS proposed rule included changes CMS proposed on the issue of “gap-filling,” a pricing methodology for new items and services under the DMEPOS benefit. Those regulatory changes focused on a process known as “inherent reasonableness” or “IR.” IR is an extensive regulatory process that CMS can use to adjust prices downward or upward if the reimbursement level for a particular DMEPOS item or service is found to be either grossly excessive or grossly deficient, and therefore not inherently reasonable. CMS can use the IR process to increase or decrease fee schedule amounts by 15% or more. In order to address confusion about how CMS determines whether items and services are “comparable” to previously available items or services for the purpose of determining to apply the gap-filling pricing methodology, CMS has proposed in this year’s rule to establish a set framework in regulation for identifying comparable items. In the proposed rule, CMS identifies five main categories on which new DMEPOS items can be compared to older DMEPOS items: physical components; mechanical components; electrical components (if applicable); function and intended use; and additional attributes and features. This evaluation will be applied to new DMEPOS items without a pricing history. If it is determined that the new item is comparable to older existing item(s), CMS proposes to use the fee schedule amounts for the older existing item(s) to establish the fee schedule amounts for the new item. If it is determined that there are no comparable items to use for gap-filling purposes, the fee schedule amounts for a new item would be based on other sources of commercial pricing data to establish Medicare payments, such as internet retail prices or information from supplier invoices. The commercial prices would then be deflated to the fee schedule base period (i.e., 1987) and updated by the covered item annual inflation factors (i.e., Consumer Price Index-Urban Consumers). [Note: This aspect of the rule illustrates the outdated system CMS uses to set reimbursement levels for new assistive devices and technologies.] Finally, when commercial pricing data is not available, unverifiable or insufficient to determine fee schedule amounts, CMS proposes to utilize technology assessments (either internally or by contracting with outside companies) analyzing samples of the products as well as older items to determine relative supplier costs of furnishing the item. CMS notes that the gap-filling method proposed may result in excessively high fee schedule amounts when a competitive market for a given new item has not yet developed. The rule thus proposes that CMS perform a one-time adjustment by conducting gap-filling a second time if prices drop notably. Specifically, if
the supplier or commercial prices used to establish fee schedule amounts for a new item decrease by any amount below 15% within five years of establishing the initial fee schedule amounts, and the amounts calculated using the new prices would be no more than 15% lower than the initial amounts, CMS proposes to have the authority to conduct a second round of gap-filling. In other words, if the IR process is not triggered by supplier and commercial prices for a particular item or service (e.g., the price of an item drops more than 15%), CMS is empowering itself to use a second gap-filling process to reduce prices, as long as the decrease is less than 15%. The rationale for this adjustment is that new, lower prices would likely represent a more stable and competitive market (established over the course of the five year period after it is available to the public), and should serve as the basis for the fee schedule amounts for the item or service. [Note: While the gap-filling and related reimbursement proposals in the DMEPOS rule are complex, they lay the foundation for CMS to essentially do whatever it wants with respect to setting reimbursement levels of new assistive devices and technologies for people with injuries, illnesses, disabilities and chronic conditions. This level of plenary authority is of great concern to manufacturers and innovators that have choices as to where they spend their time, efforts and resources. A major fear of the proposed rule is that the reimbursement provisions will expose the fragility of the return on investment (ROI) equation in the DMEPOS space and force innovators to move onto other areas, stifling investment and advancement in the DMEPOS field.] “Master List” of Items Eligible for Prior Authorization and other Requirements Since 2012, CMS has required various categories of DMEPOS items, such as power mobility devices (PMDs), to include faceto-face patient encounters with practitioners, and written prescriptions before furnishing the items to beneficiaries. Additionally, certain DMEPOS items are eligible for prior authorization, currently listed on a “Master List of Items Frequently Subject to Unnecessary Utilization.” The proposed rule would adopt a new, singular “Master List” of items potentially subject to prior authorization and/or the face-to-face encounter and written order requirement. The expanded Master List would increase the number of DMEPOS items potentially eligible to be selected for the Required Prior Authorization list, but CMS states in the rule that there are no plans to “exponentially increase the number of items subject to required prior authorization in the near future.” CMS proposes to add a large number of new Healthcare Common Procedure Coding System (HCPCS) Level II codes to combined Master List, encompassing in total 306 DMEPOS items that are newly eligible for the prior authorization, written order and faceto-face encounter requirements. One hundred forty-four of these are “L” codes, representing a significant expansion of potential eligibility of orthotics and prosthetics to prior authorization. There is little evidence or justification in the proposed rule to support this dramatic expansion of prior authorization eligibility.
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CMS proposes that the Master List would “self-update” according to a set of specified eligibility criteria at least annually, with the option to update the list more frequently on an as-needed basis. The criteria to be used to impose prior authorization on DMEPOS codes listed on the Master List include geographic location, item utilization or cost, system capabilities, emerging trends, vulnerabilities identified in official agency reports, or other analysis in selecting items for national or local implementation. Competitive Bidding Program (CBP) Amendments The proposed rule includes minor changes to the existing DMEPOS CBP regulations on change of ownership (CHOW) for recipients of competitive bidding contracts. This proposal appears to make it easier for DMEPOS suppliers that secure competitive bidding contracts from CMS to enhance the value of their company by doing so, and then sell the company (i.e., with the government contract) to another DMEPOS supplier that did not take part in the initial bidding process. Currently, regulations require contract suppliers to notify CMS 60 days in advance when negotiating a CHOW. The new regulations would apply to all entities, regardless of whether a “new” entity is formed as a result of a CHOW, and require the successor entity to submit its signed novation agreement to CMS no later than 10 days after the effective date of the CHOW. It is not clear from the proposed rule why CMS proposes this change other than regulatory burden reduction. Standardized Elements for DMEPOS Written Orders/Prescriptions The proposed rule would create one standardized set of required elements for all DMEPOS orders, including orthotics and prosthetics. CMS’s rationale for this is to reduce confusion and ease the burden on electronic medical record vendors, as well as DMEPOS suppliers who provide services across the DME and O&P benefit continuum. Specifically, CMS proposes the following elements to be included in all DMEPOS orders/prescriptions:
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1. 2. 3. 4. 5. 6.
Beneficiary name or Medicare Beneficiary Identifier (MBI); General description of the item; Quantity to be dispensed, if applicable; Date; Practitioner name or National Provider Identifier; and Practitioner signature.
The proposed rule acknowledges that these required standardized order elements are typically written on a prescription/order, but that some of these required elements may be found in the beneficiary’s medical record. Therefore, CMS proposes to amend its regulations to state that the DME MACs shall consider the totality of the medical records when reviewing for compliance with standardized order/prescription elements, which are considered conditions of payment. Conclusion The 2020 DMEPOS proposed rule includes major regulatory changes that are expected to affect reimbursement levels and regulatory processes that could lead to interruptions in patient care, such as a dramatic expansion of prior authorization. Given the existing HCPCS coding process, which tends to disincentivize innovation and new technology, the changes in this proposed rule may seem benign on its face, but create major concerns for Medicare patients who rely on DMEPOS to be functional and independent, and the providers and suppliers who serve Medicare beneficiaries with injuries, illnesses, disabilities, and chronic conditions. Written by Peter W. Thomas, Principal, Christina A. Hughes, Counsel, and Joseph Nahra, Manager of Government Affairs, the Powers Law Firm.
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Stay informed! Order your PAC report today. AMRPA Members Receive Reports at Discounted Rates. Visit www.amrpa.org/PAC-Market-Analysis-Reports for more information, or contact Julia Scott, AMRPA Member Services Coordinator, jscott@amrpa.org.
AMRPA Magazine / September 2019 13
Rehabilitation Hospitals Encouraged to Comment on CMS’s Proposed Hospital Transparency Requirements The Centers for Medicare and Medicaid Services (CMS) issued a proposal to increase price transparency by: (1) making machine-readable chargemasters publicly available would enable the development of price transparency tools for consumers; and (2) publishing patients’ out-of-pocket costs for scheduled health care (i.e., “shoppable” services). The rule explicitly states that inpatient rehabilitation facilities (IRFs) are included in the definition of a hospital. The Agency estimates that the annual burden for hospitals to review and publish their standard charges would equal 12 hours, the equivalent of $1,017.24, per hospital.
Martha M. Kendrick, Esq., Partner, Akin Gump Strauss Hauer & Feld LLP
Julie Nolan Senior Policy Advisor, Akin Gump Strauss Hauer & Feld LLP
The proposals were included in the Calendar Year (CY) 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS-1717-P). The transparency new requirements will apply to inpatient and outpatient hospitals. CMS proposes to require hospitals to make public gross charges and payer-specific negotiated rates. The Agency would require hospitals to make standard charge information publicly available through a machine-readable file and a consumer-friendly display of common “shoppable services,” which are services that can be scheduled in advance by a patient. CMS proposes a list of shoppable services for which hospitals must provide payer-specific information for as many of the 70 services as possible, plus public charges additional services for a total of 300 shoppable services based on utilization or billing rate of the services in the past year. Hospitals that fail to comply will be subject to a maximum fine of $300 per day, effective July 1, 2020. CMS is seeking comments on the following: The potential unintended consequences of publishing payer-specific negotiated rates and whether there may be different ways to help patients understand their expected out-of-pocket costs in advance of receiving care; Alternative and additional types of standard charges that may be helpful to consumers; The proposed data elements for the machine-readable file as well as elements that the Agency considered but is not proposing at this time; The 70 shoppable services identified;
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Whether there should be a requirement to publish charges for more or less than 300 shoppable services and whether 100 shoppable services (or less) is an appropriate starting point;
The proposed amount of the civil monetary penalty (CMP) and the publication of the imposition of a CMP and whether these enforcement actions are reasonable to ensure hospitals’ compliance;
Whether CMS should establish more specific requirements related to the shoppable services, such as requiring hospitals to publish charges for their most frequently billed shoppable services that are not included in the list of 70 shoppable services;
The potential unintended consequences of the proposed penalties for noncompliance and whether other penalties should apply; and
Whether there are other data elements that should be published in the consumer-friendly display; How to ensure consistency of consumer-friendly data availability across hospital settings and whether the proposals provide for a useful amount of data that allow for actual comparisons of “shoppable” items and services;
Whether CMS should establish a different noncompliance penalty appeals processes. Comments on the rule are due on September 27, 2019, and the rule would go into effect on January 1, 2020.
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AMRPA Magazine / September 2019 15
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16 AMRPA Magazine / September 2019
Staff Education and Testing for QRP Changes
Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.
Staff education should be well underway for the new sections GG- and H-based case-mix groups (CMG). This article focuses on modeling staff education to ensure optimal CMG capture for medical rehabilitation patients. Let me start by saying that all clinicians should be educated or re-educated. Every single clinician in your hospital or unit will benefit from listening to the message on the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) scoring again. Therapists, since therapy minutes were added to the IRF-PAI in 2016, have largely been the ones to bear the burden of scoring the section GG items. In those days, we took great steps to ensure clinicians did not confuse the section GG scoring rules with FIM™ scoring rules. It is my belief that we therefore did not really teach clinicians how to properly score section GG. It is time to tackle that now. Nurses need to be part of the scoring equation for the section GG and H items. I advocate that you find ways to use the information you are currently gathering on the input and output flowsheet (I&O) to populate the section H continence items. Typically, nurses are tasked with recording all continent and incontinent episodes, but they may forget or feel that they have communicated their intent with one entry per shift. To obtain correct bladder and bowel continence scores for section H, all continent and incontinent episodes should be recorded. Further, nurses are the first clinicians to encounter new patients. Per the instructions in the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) manual and in the effort to gather scores as close to the time of admission as possible, nurses should complete an admission assessment that includes section GG items. I believe that nurses should be trained on all section GG items, but I realize that there are some items that they will encounter and assess more frequently than others. To that end, the items that are of the greatest importance for nursing assessments include eating, oral hygiene, toileting, bed mobility, and transfers. Physical and occupational therapists should also complete education sessions focused on the definitions of the scores, with emphasis on both scoring prior to initiating intervention as well as scoring based on prior device use. They will need to review each item and address inclusions and exclusions, particularly in the area of the self-care function items. Remind therapists that the amount of assistance applying and removing a device such as a back brace, compression socks, or an incontinence brief all factor into the score for the respective items. For the mobility items, it is critical to remind therapists that the assessments are meant to be conducted sequentially, which might impact the patient’s level of participation if they grow increasingly more tired. Some of the special considerations for the section GG self-care items include: Eating: The amount of assistance provided for tube feeding is not part of the assessment. Patients who receive tube feeding or total parenteral nutrition (TPN) as their only source of nutrition or hydration would be scored 88 (Not safe due to a
AMRPA Magazine / September 2019 17
medical condition or safety) or 09 (Not applicable) depending on how long they have received tube feeding. Oral hygiene: Measure the amount of assistance the patient needs with brushing their teeth or cleaning their dentures. This includes soaking, rinsing and applying or removing dentures. Toileting hygiene: The item should incorporate hygiene related to the opening of an ostomy bag if that applies. Bathing: The item incorporates all body parts except the back and hair. It includes face washing. Measure the amount of assistance needed to wash, rinse and dry the body parts. Upper body dressing: Measure the amount of assistance needed with clothing and devices such as a back brace, neck brace, sling, edema wrapping, prosthetic or orthotic, etc. Lower body dressing: Measure the amount of assistance needed with clothing and underwear including an incontinence brief, prosthesis, edema wrapping, stump sock or shrinker, etc. Footwear: Measure the amount of assistance needed with socks and shoes including compression socks, an ankle-foot orthotics, etc. For the mobility items, measure the patient’s ability to complete the items based on how they performed prior to the illness or injury. The clinician should, for example, have a script ready to explain why they are testing bed mobility on a flatbed without rails. It is important to convey that you are conducting an assessment and want to see how the patient completes the task with equipment similar to what they have available at home. Conducting an assessment in that manner will help you approximate the amount of time the patient will be in the rehabilitation hospital or unit. Per the IRF-PAI manual, the mobility items should be tested sequentially. That means that each walking, wheelchair and stairs task should be
18 AMRPA Magazine / September 2019
// The exam system expands your arsenal of tools to help you prepare your staff for the switch to GG/H-based CMGs. The QRP certification exams will help you determine where staff education is needed, enabling an efficient, targeted approach to preparedness. measured one at a time. Because walking and mobilizing a wheelchair around turns is different than going in a straight line, these items should be completed as separate assessments. Complete your education sessions now. Clinicians need time to practice. Going live with nursing scoring immediately will be a helpful way to identify knowledge gaps. Once everyone has benefitted from an education session, test their knowledge. AMRPA and eRehabData® are offering an IRF QRP Certification Exam that is free of charge to eRehabData® subscribers and AMRPA members. The exam system expands your arsenal of tools to help you prepare your staff for the switch to GG/H-based CMGs. The QRP certification exams will help you determine where staff education is needed, enabling an efficient, targeted approach to preparedness. While there is no regulatory requirement for QRP certification, these exams are an easy way to gauge how adept your nurses, therapists, and PPS coordinators are on scoring specific QRP items. Give it a try.
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AMRPA Magazine / September 2019 19
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CMS Finalizes FY 2020 IRF PPS Rule
Final Rule Includes Unweighted Motor Score, New IRF-PAI Items, and Other Significant Policy Changes for Upcoming Payment Year
On July 31, 2019, the Centers for Medicare and Medicaid Services (CMS) finalized its federal fiscal year (FY) 2020 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Final Rule. Payment provisions of the rule are effective for discharges on or after October 1, 2019 (FY 2020), and the new quality reporting requirements go into effect October 1, 2020 (FY 2021). Overall, CMS estimates that the final rule will result in a 2.5% increase in payments to IRFs in FY 2020, relative to FY 2019.
Kate A. Beller, JD, AMRPA Executive Vice President for Policy Development and Government Relations
The American Medical Rehabilitation Providers Association (AMRPA) engaged extensively with CMS throughout the rulemaking period via email correspondence and the submission of two comment letters. AMRPA weighed in on nearly every issue raised in the proposed rule, and advocated for numerous major policies that were included in the final rule, including: CMS used two years of data (FY 2017 and FY 2018) in developing the FY 2020 casemix groups (CMGs). In line with AMRPA’s advocacy on current and past IRF PPS rulemakings, CMS is adopting the use the current year’s inpatient hospital prospective payment system (IPPS) wage index, which will align IRF payment adjustments to other sites of care in a timelier manner. In line with AMRPA’s comments, CMS is not finalizing its proposal to expand IRF-PAI data collection to all patients (regardless of payer) at this time. Under the final rule, CMS will allow the IRF – rather than a Medicare contractor – to assess a provider’s compliance with the existing rehabilitation physician criteria AMRPA will closely analyze the impact of the final rule on the industry, particularly with respect to payment adequacy and patient access to inpatient rehabilitation. A full summary of the rule follows. IRF PAYMENT POLICY PROVISIONS Case-Mix Policy Changes: Consistent with its policy adopted in the FY 2019 IRF PPS final rule, CMS finalized revisions to the new classification system for the IRF PPS casemix groups (CMGs) based on the Quality Indicator section of the IRF Patient Assessment Instrument (IRF-PAI) (specifically sections GG and H). The Functional Independence Measure (FIM™) and Functional Modifiers will officially be removed from the IRF-PAI effective October 1, 2019.
AMRPA Magazine / September 2019 21
Additionally, and consistent with the FY 2020 proposed rule, communication and memory scores will be not be determinants for the final FY 2020 CMGs. CMS notes that it found “including these cognitive items in generating the CMGs would have resulted in lower payments for patients with higher cognitive deficits.” CMS adds, however, that it will consider feedback that it received from stakeholders that encourage the agency to incorporate improved cognition measures into the IRF-PAI in future rulemakings. AMRPA has expressed its concern about the lack of a cognitive element in the FY 2020 CMGs and will work with CMS as it engages in further research on this issue. Unweighted Motor Score: In a policy significant change, CMS has adopted an unweighted motor score to assign patients to the FY 2020 CMGs rather than the weighted motor score included in the FY 2020 IRF PPS proposed rule. In the final rule, CMS repeatedly notes it believes that the proposed weighted motor score “results in a slight improvement” in the ability of the IRF PPS to predict patient costs and thus the accuracy of IRF PPS payments. However, following “careful consideration” of stakeholder feedback on the weighted/unweighted motor score issue, the agency ultimately decided to use an unweighted motor score because it is “conceptually simpler” and will help ease providers’ transition from the FIM™ to the use of section GG/H items. CMS states that it will take stakeholder comments on its weighted motor score into consideration as it evaluates possible future refinements to the case-mix methodology. CMS’ decision to finalize an unweighted motor score required its contractor, the Research Triangle Institute (RTI), to rerun its Classification and Regression Tree (CART) analysis and recalculate CMGs with an unweighted motor score. The recalculation resulted in changes to the number of CMGs included in each RIC, described in more detail below. Finalized Motor Score Items: Consistent with the FY 2020 IRF PPS proposed rule, CMS finalized the removal of one item – GG0170A1 (Roll left and right) – from the motor score. Also consistent with previously finalized policy, wheelchair mobility items are omitted from the FY 2020 motor score. CMS reiterates the explanation provided in the FY 2019 IRF PPS final rule, stating that the higher resource needs of wheelchair-dependent patients in IRFs will be better accounted for by not including a wheelchair item in the motor score. Specifically, CMS notes that patients who are considered wheelchair dependent or unable to walk “will be accounted for through the ‘not attempted’ response codes captured through other items, especially some of the walking items, that are included in the motor score.” CMS adds that it believes that IRFs will be appropriately compensated for the higher costs they incur in treating wheelchair-dependent patients. In total, the finalized motor score index includes the 18 unweighted data item in the following table provided by CMS:
22 AMRPA Magazine / September 2019
FY 2020 CMG Relative Weights and Average Length of Stay As described above, the FY 2020 IRF PPS rule incorporates an unweighted motor score in the calculation of the FY 2020 CMGs. Because the weighted motor score was a “key input” in the CMG, relative weights, and average length of stay calculations, the CART analysis had to be rerun to utilize the new (unweighted) motor score. As such, the final FY 2020 CMGs, relative weights, and average lengths of stay (ALOS) values differ from those in the proposed rule. Key changes include: The final rule includes three more CMGs than included in the proposed rule (100 vs. 97) Stroke RIC (01) will have six CMGs, compared to seven in the proposed rule Non-traumatic spinal cord injury RIC (05) will have five CMGs, compared to four in the proposed rule Replacement of lower extremity joint RIC (08) will have five CMGs, compared to four in the proposed rule Rheumatoid other arthritis CMG RIC (13) will have five CMGs, compared to four in the proposed rule Major multiple trauma without brain or spinal cord injury RIC (15) will have five CMGs, compared to four in the proposed rule The final rule continues to factor patient age into CMGs in RICs 1, 3, 4, 12, 13, and 20, consistent with the proposed rule. Currently, age only affects assignment for CMGs in RICs 1, 4, and 8. In the final rule, however, age will no longer factor into CMG assignment for RIC 16, as it did in the proposed rule. With respect to the financial impact of the final FY 2020 CMGs and other payment policies in the rule, CMS’ provides the following estimates:
IRFs in rural areas would experience a 4.4% increase in average payment, up from the 1.8% increase estimated in the proposed rule. Rural units would see a 5.7% increase, while rural freestanding hospitals would see a 2.1% decrease Urban IRFs would experience a 2.4% increase, compared to the 0.1% decrease estimated in the proposed rule. Urban units would see a 5.0% increase, while urban hospitals would see a 0.2% increase. CMS Commentary on the Initial Proposed Weighted Motor Score: The final rule acknowledges that many commenters – including AMRPA – provided extensive comments on the proposed weighted motor score, including concern about the data provided on the assignment of weights under the proposed motor score (for example, the sizeable increase in the weight assigned to the eating item). While this commentary is not immediately applicable to the FY 2020 case-mix policy in light of CMS’ decision to finalize an unweighted motor score, AMRPA is closely analyzing CMS’ comments on the weighted motor score in the event this type of proposal resurfaces in future rulemaking. For example, CMS acknowledges that it received numerous comments (including from AMRPA) on the perceived increase in the weight for the eating item under the proposed weighted motor score. To this issue, CMS explained that “key differences in the coding guidelines between the FIM eating item and the section GG eating item may have contributed to the change in the relative importance of this item for predicting IRF costs.” Additional information, such as how tube feeding is scored differently under the FIM™ versus the Section GG/H system, are addressed in greater detail in the final rule. CMS also acknowledges that some commenters – again including AMRPA – asked CMS to provide additional information regarding the provider specific impact analysis file that accompanied the rule, such as a data dictionary. CMS responds that the provider-specific impact files enable providers to see how their individual payments would be affected by the CMG changes, and that CMS “believe[s] that this additional information is responsive to commenters’ requests.” FINANCE AND LABOR POLICY CHANGES CMS finalizes its proposed changes to the IRF PPS market basket with only slight changes to the weights and price proxies. The agency also adopts its plan to use the current year’s inpatient hospital prospective payment system (IPPS) wage index, which will align IRF payment adjustments to other sites of care in a timelier manner. CMS finalizes its notable 2% increase in the labor-related share, which will result in larger differences in payments across different geographic regions. The IRF standard payment rate will rise to $16,489, an increase of about $450. Rebasing of IRF PPS Market Basket CMS proposed to update the weights and price proxies used to calculate IRF PPS market basket. The market basket is the mix of goods and services representative of services provided in an IRF. The current market basket is based on 2012 cost reports, and CMS has proposed and now finalized an update to the market
basket using 2016 cost reports. As proposed, CMS will use very similar weights and price proxies to what are used in the current market basket. However, CMS is finalizing its proposal to change how it calculates and weights home office contract labor costs. CMS will proceed with using Medicare cost reports, rather than external data, to calculate home office contract labor costs. In addition, home office contract labor costs will consist of its own major weighted category, weighted at 3.7%, rather than being a subcategory in the residual cost category. CMS provided a table – copied below – that outlines the updated weights for each major category in the new finalized Market Basket. CMS says despite this change, it forecasts the new market basket to grow at almost the same rate over the next several years as the current market basket.
Wage Index Changes Historically, the wage index used to adjust facility-specific payment for IRFs relied on the previous year’s acute-care hospital (IPPS) wage index. AMRPA has consistently advocated for CMS to utilize the most recent year's IPPS wage index for IRFs, and supports CMS’ decision to finalize this proposal in the final rule. As a result of this policy change, IRFs will no longer be receiving wage adjustments based on wage shifts one year later than acute-care hospitals receive updates. CMS also noted that the proposed rule contained an error in the figures provided for hospital’s wage index values. CMS said it was unable to correct the error prior to the comment period closing, but that updated figures have been provided as part of this final rule. Hospitals should check for changes from the proposed rule in the rate setting files provided as part of this year’s final rule. Labor Related Share Update For IRF payment purposes, the region-specific wage index is applied to the labor-related share of IRF payment to determine a facility-specific payment. Due to the use of updated data from more recent cost reports, CMS proposed a labor-related share of 72.6%, which is notably higher than the FY 2019 share of 70.5%. Based on data that has been updated since the proposed rule, CMS used the same methodology it had proposed to finalize a slightly higher labor-related share of 72.7%. This means that hospitals will see greater regional variation in payments, particularly for very high or low wage index hospitals. Standard Payment Conversion Rate CMS proposed to update the standard payment conversion factor using the newly updated market basket. CMS’ original forecast of the market basket showed an increase of 3%, which it proposed to use for FY 2020. However, using additional data since the proposed rule, an updated forecast predicts a 2.9% growth in the
AMRPA Magazine / September 2019 23
IRF market basket, which CMS has decided to use for this final rule.
CMS also adjusts the standard rate based on a statutorily required productivity factor, which it estimated in the proposed rule to be -0.5% based on Bureau of Labor Statistics data. However, again using updated data for the final rule, CMS finalized a slightly adjusted productivity factor of -0.4%. Therefore, CMS has finalized the same update of 2.5% to the standard payment conversion factor that it originally proposed, albeit based on slightly different underlying figures. CMS is also required to apply a budget neutrality factor due to any changes in CMGs and any changes to the labor-related share and wage index. After applying these factors, CMS originally proposed an increase from $16,021 to $16,573. However, based on the updated data, CMS has finalized a slightly lower standard payment conversion factor of $16,489. A table provided by CMS (copied below) breaks down CMS’ computation of the final standard payment conversion factor. The final rule also provides data on the unadjusted payment rate for all CMGs and tiers based on this updated payment factor. Outlier Threshold and Cost-To-Charge Ratio In the FY 2020 proposed rule, CMS proposed to update the outlier threshold amount from $9,402 for FY 2019 to $9,935 for FY 2020 to ensure outlier payments continue to account for 3% of total payments. However, based on changes it made to other proposals, including payment rates, CMS has finalized an outlier threshold of $9,300, which is what it estimates will accomplish its goal of outliers remaining as 3% of total payments. CMS also finalized a national cost-to-charge (CCR) ceiling of 1.31 for FY 2020, as well as estimated a national average CCR of 0.5 for rural IRFs and 0.405 for urban IRFs. Facility Adjustment Factors As CMS stated in the proposed rule, it will continue to use the same low-income pool (LIP), rural, and teaching adjustment factors it has used since FY 2014. The factors are: LIP factor: 0.3177 Rural adjustment: 14.9% Teaching adjustment: 1.0163 REHABILITATION PHYSICIAN DEFINITION In the final rule, CMS adopted its proposal to amend the IRF regulations to clarify that the IRF itself is to determine whether a physician is appropriately qualified to serve as a rehabilitation 24 AMRPA Magazine / September 2019
physician. The final rule makes no changes to the current regulatory criteria governing rehabilitation physicians, which require that a rehabilitation physician be a licensed physician with specialized training and experience in inpatient rehabilitation. CMS stated in the final rule that that this change clarifies for hospitals and auditors “that the responsibility is, and always has been, on the IRF to ensure that the rehabilitation physician(s) who are making the admission decisions and treating the patients have the necessary training and experience.” In its commentary, CMS states that it “expect[s] that IRFs will continue to ensure that the rehabilitation physicians treating patients in their facilities have the necessary training and experience in inpatient rehabilitation” under this finalized policy. It adds that the agency will continue to work with stakeholders to refine Medicare’s IRF payment policies in the future “so that they support IRFs in providing the highest quality care to beneficiaries.” QUALITY REPORTING PROGRAM (IRF QRP) For the IRF Quality Reporting Program (IRF QRP), major finalized policies include: The adoption (as proposed) of two new Transfer of Health Information measures to meet requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act starting October 1, 2020. The finalization of a series of new standardized patient assessment data elements (SPADEs) to the IRF-PAI, which will be required for Medicare patients discharged on or after October 1, 2020. The SPADES are more fully detailed below Overall, CMS estimates that reporting the SPADEs will add 7.8 minutes to the patient admission assessment and 10.95 minutes to the discharge assessment, for a total of 18.8 minutes of additional clinical staff time to report data per patient stay. CMS estimates the IRF QRP reporting policies will add $8.2 million in provider costs in FY 2020 for all IRFs, or $7,339 per IRF on average. While CMS does not finalize its proposal to expand IRF-PAI data collection to all patients regardless of payer, it states it plans to propose the policy in future policymaking. QRP Measure Provisions CMS is adopting the following two measures to the IRF QRP, and data collection will be required for Medicare Part A (FFS) and Part C (Medicare Advantage) discharges on or after October 1, 2020: Transfer of Health Information to the Provider
Transfer of Health Information to the Patient The measures are process-based measures that assess whether or not a “current reconciled medication list” is given to either the subsequent provider or to the patient/family/caregiver when the patient is discharged or transferred from his or her current PAC setting. The measures will be collected via new IRF-PAI items. With regard to reporting burden, CMS estimates that the new measures combined will add 1.2 minutes in clinical staff time per patient
stay to report the data. Providers’ compliance with reporting the measures will be taken into account for the purposes of determining their FY 2022 IRF QRP payment update and beyond. Additionally, CMS finalized its proposal to revise the Discharge to Community – Post Acute Care measure to exclude baseline nursing facility residents from the measures beginning with the FY 2020 IRF QRP. Baseline NF residents are defined as those who had a long-term NF stay in the 180 days preceding their hospitalization and IRF stay.
SPADEs Requirements – New IRF-PAI Items Effective FY 2021 IMPACT Act Domain
SPADE for Data Collection on the IRF-PAI
Cognitive Function and Mental Status
Brief Interview of Mental Status (BIMS) (currently on the IRF-PAI) Confusion Assessment Method (CAM) Patient Health Questionnaire-2 (PHQ-2) Patient Health Questionnaire-9 (PHQ-9)
Special Services Treatments and Interventions (SSTI)
Cancer Treatment – Chemotherapy (IV, Oral, Other) Cancer Treatment – Radiation Respiratory Treatment – Oxygen Therapy Respiratory Treatment – Suctioning Respiratory Treatment – Tracheostomy Care Respiratory Treatment – Non-invasive Mechanical Ventilator (BiPAP, CPAP) Respiratory Treatment – Invasive Mechanical Ventilator Intravenous Medications (Antibiotics, Anticoagulants, Vasoactive Medications, Other) Transfusions Dialysis (Hemodialysis, Peritoneal dialysis) IV Access (Peripheral IV, Midline, Central line) Nutritional Approach – Parenteral/IV Feeding Nutritional Approach – Feeding Tube Nutritional Approach – Mechanically Altered Diet Nutritional Approach – Therapeutic Diet High-Risk Drug Classes – Use and Indication
Medical Condition and Comorbidity Data
Pain Interference
Impairment Data
Hearing (at admission only) Vision (at admission only)
Social Determinants of Health
Race (at admission only) Ethnicity (at admission only) Preferred Language (at admission only) Interpreter Skills (at admission only) Health Literacy Transportation Social Isolation
AMRPA Magazine / September 2019 25
Pursuant to the IMPACT Act, CMS is required to develop and collect standardized patient assessment data across PAC. In this rule, CMS is adopting all of the SPADEs it proposed, including those on social determinant of health (SDOH). IRFs will be required to report t hese SPADEs for all Medicare Part A (fee-for-service) and Part C (Medicare Advantage) patients discharged on or after October 1, 2020 at admission and discharge, with the exception of certain SPADEs (see below) which are required at admission only. Providers’ data submission for the SPADEs will be used to determine FY 2022 IRF QRP compliance. CMS has or will be providing a number of documents, including a final mock-up of the new IRF-PAI items and Training Manuals, to educate stakeholders on the SPADEs prior to their October 2020 effective date. In the final rule, CMS provided feedback to stakeholder comments on certain SPADES: Special Services Treatments and Interventions SPADEs: With respect to the timing of the collection of these items, CMS asserts that it is “clinically appropriate and important to the ultimate usefulness of these SPADEs that they are collected with respect to both admission and discharge.” CMS says will take under consideration stakeholder recommendations, including AMRPA’s, to explore the feasibility of collecting information on special services, treatments, and interventions through claims-based data. High-Risk Drug Classes SPADE: CMS acknowledges that it received comments that the information recorded by this SPADE will be redundant with Medicare’s hospital Conditions of Participation (CoP). CMS responds that it disagrees with this position, as “CoPs provide guidance on clinical practice, while the proposed SPADEs attempt to collect information about individual patients in order to understand clinical acuity and to populate a core set of information that can be exchanged with the patient across care transitions.” Social Determinants of Health SPADEs: CMS similarly notes that it disagrees with certain comments received on the SDOH SPADEs, such as the stakeholders’ recommendations that IRFs should have the flexibility to assess these SPADEs at any point during the patient stay (instead of strictly at admission). CMS asserts that each of the SDOH SPADEs will assist with care planning when the patient is admitted. With the exception of the Race, Ethnicity, Preferred Language, and Interpreter Services SPADEs, CMS says that the responses to other SDOH SPADEs are likely to change from admission to discharge for some patients and hence requires that providers report the data at discharge as well. All-Payer Data Collection In the final rule, CMS does not adopt its proposal to expand the reporting of IRF-PAI data to all-payer patients. If the policy were
26 AMRPA Magazine / September 2019
adopted, providers would have needed to submit IRF-PAI data on patients across all payers starting October 2020 in order to be compliant with Medicare’s IRF QRP reporting requirements and not receive the 2% IRF PPS payment reduction for noncompliance. In this final rule, CMS acknowledged the concerns raised by AMRPA and other commenters with respect to the administrative challenges of implementing all-payer data reporting in the Medicare program, the need to account for the burden related to this policy, as well as the need for the agency to provide further detail and training to IRFs. CMS says it plans to propose all-payer data collection and will provide an estimate of the associated burden in future. AMRPA urged CMS to not finalize the all-payer policy in this year’s rule given the lack of implementation details and supports CMS’ decision to delay this policy. AMRPA will closely track CMS’ future efforts to require reporting of IRF-PAI data to all-payer patients. Policies for the Public Display of Measures CMS finalized its proposal to publicly report the Drug Regimen Review measure on IRF Compare in CY 2020 or as soon as technically feasible. As with other quality information on IRF Compare, the displayed data will based on four rolling quarters and initially use discharges from January 1, 2019 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. Other Quality-Related Policies Effective October 1, 2019, CMS will migrate to Internet Quality Improvement and Evaluation System (iQIES), that will enable realtime upgrades and other features such as allowing more than two users per-facility. CMS is designating iQIES as the data submission system for the IRF QRP beginning October 1, 2019 and is updating the related regulation text. Finally, CMS adopted its proposal to cease publishing annually a list of IRFs that were compliant with IRF QRP reporting requirements. CMS also states that it does not, at this time, plan to make the list of compliant IRFs available upon request, as Medicare’s other QRPs also do not provide this information. *** AMRPA will be closely analyzing the impact of the CMG policies, finance and labor provisions, and QRP provisions included in the final rule and assess the impact on our industry and patients. AMRPA is very appreciative of input from the Regulatory and Legislative Policy Committee, Quality Committee, and various workgroups in helping to develop the Association’s proposed rule comments, and we thank the membership at large for their advocacy efforts during this rulemaking.
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MedPAC Issues 2019 Data Book on Medicare Utilization and Spending Trends
Mimi Zhang, AMRPA Director of Payment Innovation, Quality and Research
In July, the Medicare Payment Advisory Commission (MedPAC) published its annual compendium of Medicare utilization and payment information, June 2019 Data Book: Health Care Spending and the Medicare Program. The volume presents updated statistics from 2017 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. Overall, Medicare spending is concentrated in certain services and has shifted over time
MedPAC’s observations: In 2018, Medicare spending totaled $737 billion for benefit expenses. Managed care (Medicare Advantage) was the largest spending category (32%), followed by inpatient hospital services (20%), and prescription drugs under Part D (13%). Medicare managed care enrollment has increased 82% between 2010 and 2018 (data not shown). Spending for inpatient hospital services was a smaller share of total Medicare spending in 2018 than it was in 2009, falling from 26% to 20%.
AMRPA Magazine / September 2019 29
Number of post-acute care providers decreased slightly in 2018 2014
2015
2016
2017
2018
Average annual% change, 2014-2418
Percent change, 2017-2018
HHAs
12,461
12,346
12,204
11,844
11,783
-1.6%
-0.5%
IRFs
1,177
1,182
1,188
1,178
1,170
-0.1
-0.7
LTCHs
422
426
423
411
386
-2.2
-6.1
SNFs
15,173
15,223
15,263
15,277
15,230
0.1
-0.3
Post-Acute Care The supply of IRFs has been relatively stable since 2014. Most inpatient rehabilitation providers are distinct units in acute-care hospitals; about a quarter of IRFs are freestanding hospitals. However, because hospital-based units tend to have fewer beds, they only account for about half of Medicare IRF discharges. 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. After peaking in 2012 (data not shown), the number of long-term care hospitals (LTCHs) has decreased. MedPAC attributes the decline to the implementation of a new “dual payment-rate structure” that reduces payments for certain Medicare discharges from LTCHs beginning in fiscal year 2016. The total number of skilled nursing facilities (SNFs) has increased slightly since 2009, and the mix of facilities has shifted from hospital-based to freestanding facilities. In 2018, hospital-based SNF made up 4% of all facilities, down from 8% in 2005 (data not shown). Growth in Medicare’s fee-for-service post-acute care expenditures has slowed since 2011 Aggregate fee-for-service (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). FFS PAC expenditures have remained flat since 2012. FFS spending on IRFs declined from 2004 through 2008, which MedPAC attributes to payment policy changes during that period. However, spending on IRFs has since increased and grew from $6.0 billion in 2008 to $7.9 billion in 2017.
30 AMRPA Magazine / September 2019
In 2017, payments to SNFs and HHAs combined constituted 48.7 of total PAC expenditures in Medicare FFS. FFS spending on skilled nursing facilities increased sharply in 2011, reflecting CMS’s adjustment for the implementation of the new resource utilization groups (RUGs version IV). Once CMS corrected the adjustment, SNF spending dropped in 2012 and has remained stable since. In 2017, about 43% of all Medicare FFS patients discharged from an acute care hospital were discharged to PAC services (IRF, SNF, LTCH or HHA). From 2012 to 2017, the share of Medicare FFS hospital patients discharged to home with self-care decreased 2.7%age points, while the share discharged to PAC increased 2.6%. The majority of this increase was from those discharged home with organized home health care. Between 2006 and 2015, the share of beneficiaries discharged to PAC increased about 6% (data not shown). In 2017, about 5% of beneficiaries are discharged to hospital-level PAC, to either an inpatient rehabilitation hospital or unit (3.8%) or long-term care hospital (1.1%).
Medicare FFS inpatients discharged from acute care hospitals to home self-care decreased slightly while discharges to PAC increased, 2012–2017 2012
2016
2017
Percent Change, 2012-2017
48.0%
45.7%
45.3%
-2.7%
PAC
40.9
43.2
43.5
2.6
Skilled nursing or swing bed
20.3
20.8
20.7
0.4
Home with organized home health care
15.9
17.2
17.9
2.0
Inpatient rehabilitation facility
3.5
4.0
3.8
0.3
Long-term care hospital
1.2
1.1
1.1
-0.1
Hospice, medical facility or home
2.7
3.0
3.1
0.4
Other inpatient hospital
2.8
2.7
2.7
-0.1
Nursing home or intermediate care facility
1.5
1.3
1.2
-0.2
Died in hospital
3.3
3.2
3.2
-0.1
Left against medical advice
0.8
0.8
0.9
0.1
Other
0.1
0.2
0.1
0.0
Destination Home self-care
Medicare margins of PAC providers, 2004-2017 2004
2006
2008
2010
2012
2014
2016
2017
13.8%
12.8%
16.7%
19.4%
14.1%
12.7%
11.6%
11.2%
16.7
12.4
9.3
8.7
11.1
12.5
13.0
13.8
HHA (freestanding)
16
15.4
17
19.4
14.4
10.8
15.5
15.2
LTCH
9
9.7
3.6
6.7
7.6
6.8
6.3*
5.8*
SNF (freestanding) IRF
*For cases qualifying for the LTCH PPS rate. The Pathway for SGR Reform Act of 2013 created a “dual payment-rate structure” for LTCHs where, beginning in fiscal year 2016, only certain LTCH cases continue to qualify for the standard LTCH PPS rate, while cases that do not meet a set of criteria are paid a lower “site-neutral” rate.
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 Hospitals and Units The number of fee-for-service IRF 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, 2.1% per year between 2008 and 2016. Payments per case grew 3.1% between 2016 and 2017.
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% per year. From 2008 to 2014, IRF volume increased less than 1% per year on average. While IRF volume grew between 2015 and 2016 (rising 2.4%), it has declined between 2016 and 2017 (falling 2.7%). In 2017, the number of IRF cases per 10,000 FFS beneficiaries fell to 98.5, down 2.4% from the previous year. MedPAC notes that relatively few Medicare beneficiaries use IRF services due to Medicare coverage rules. With the decline in the number of IRF cases per FFS beneficiary, the share of IRF total volume that are Medicare FFS beneficiaries fell to 58% in 2017, while the volume of IRF cases across all payers rose slightly in 2017 (data not shown).
AMRPA Magazine / September 2019 31
Number of fee-for-service IRF patients decreased in 2017 2008
2013
2016
2017
Average annual% change, 2008-2016
Number of IRF cases
356,000
373,000
391,000
391,000
1.2%
-2.7%
Cases per 10,000 FFS beneficiaries
100.4
99.1
100.9
98.5
0.1
-2.4
$16,646
$18,258
$19,714
$20,322
2.1
3.1
13.3
12.9
12.7
12.7
-0.6
0.0
2014
2015
2016
2017
19.50%
19.80%
20.10%
20.50%
Other neurological disorders
13.1
13
13.7
15.0
Brain injury
8.7
9.3
9.9
10.7
Debility
10.3
10.7
10.7
10.6
Fracture of the lower extremity
12.2
11.5
10.8
10.4
All other conditions
10.6
10.5
10.1
9.8
Other orthopedic conditions
7.7
7.9
8.2
7.9
Cardiac conditions
5.6
6
6.1
5.8
Spinal cord injury
4.6
4.7
4.9
4.9
Major joint replacement of lower extremity
7.8
6.8
5.5
4.4
Payment per case Average length of stay (days)
Percent change, 2016-2017
Most common IRF cases from 2014 to 2017
Stroke
Stroke patients were the most frequent diagnosis for IRF patients in 2017, accounting for 20.5% of all Medicare FFS IRF admissions. The volume of major joint replacements of the lower extremity has steadily decreased the recent years, while brain injury and other neurological conditions have increased. In 2004, major joint replacements were the most common IRF case and accounted for 24% of all admissions (data not shown). MedPAC notes that the number and share of neurological conditions has grown significantly. Between 2008 and 2017, the number of patients with neurological conditions almost doubled, growing by 99%, while the total number of Medicare IRF cases grew 6% over the same period (data not shown). In 2004, other neurological conditions constituted 5.2% of total IRF cases (data not shown). PAC 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 32 AMRPA Magazine / September 2019
as discharge to community or rehospitalizations (readmissions) measures, they differ in their technical details and therefore are not identical to CMS’ measures. In this year’s report, MedPAC states that quality measures based on patient assessment-based of functional status should be “interpreted carefully, given evidence that the patient assessment information reported by IRFs and HHAs may reflect financial considerations.” MedPAC’s IRF rehospitalization measures count stays that are readmitted to a hospital with the principal diagnosis of a potentially avoidable condition. These 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; diabetes-related complications; cellulitis or wound infection; pressure ulcer; medication error or adverse drug reaction; and delirium.
IRFs improved on risk-adjusted rates of discharge to the community and potentially avoidable rehospitalizations from 2012 to 2016 Measure
2012
2012
2014
2015
2016
2017
Potentially avoidable rehospitalizations during IRF stay
2.8%
2.6%
2.7%
2.6%
2.7%
2.6%
Potentially avoidable rehospitalizations 30 days after IRF discharge
4.8
4.8
4.7
4.3
4.7
4.7
Discharge to the community
74.2
74.9
75.2
75.0
75.9
76.0
Discharged to a SNF
6.9
6.9
7.1
7.0
6.8
6.8
SNFs improved on some quality measures but not others from 2011-2017 Measure
2011
2015
2017
33.2%
38.8%
40.0%
Potentially avoidable rehospitalizations during SNF stay
12.4
10.4
10.9
Potentially avoidable rehospitalizations 30 days after SNF discharge
5.9
5.0
6.1
Rate of improvement in one or more mobility ADLs
43.6
43.6
43.9
Rate of no decline in mobility
87.2
87.1
87.0
Discharge to the community
Between 2012 and 2017, the national average rate of riskadjusted potentially avoidable rehospitalizations during IRF stays declined from 2.8% to 2.6%. (Lower rates are better.) The national average rate of risk-adjusted potentially avoidable rehospitalizations within 30 days after discharge from an IRF declined from 4.8% to 4.3% in 2015, then rose to 4.7% in 2016 and 2017.
Between 2012 and 2017, IRFs’ risk-adjusted community discharge rate increased from 74.2% to 76.0% (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 readmitted to an acute-care hospital within 30 days of the IRF discharge. Quality measures for SNFs draw on two sources, claims for payment submitted by SNFs and patient assessment data collected by SNFs. MedPAC’s SNF readmission measures counts 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. MedPAC notes that SNFs functional status outcomes were essentially unchanged between 2011 and 2017. 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. The complete Data Book is available at www.medpac.gov.
AMRPA Magazine / September 2019 33
CMS Releases 2020 Physician Fee Schedule Proposed Rule
Jonathan M. Gold, JD, AMRPA Director of Government Relations & Regulatory Counsel
Highlights: »» »»
gency Details Application of Payment A Reduction for Use of Therapy Assistants CMS Cancels Plans to Consolidate Payments for Evaluation and Management Physician Visits
On July 29, the Centers for Medicare and Medicaid Services (CMS) released the Physician Fee Schedule (PFS) proposed rule for calendar year 2020. There are a number of proposals of note pertaining to both physician services and therapy services. CMS is revising its policies from last year’s rules that would have consolidated payments for evaluation and management (E/M) services provided by physicians, effective in 2021. CMS is also further clarifying how it will apply the required payment reduction for outpatient therapy services that are provided in part by therapy assistants. This article provides a high-level overview of some of the provisions in this year’s proposed rule. Comments are due on the rule by September 27, 2019. Reduction in Payment and New Modifiers for Therapy Assistants As part of the repeal of the therapy caps for outpatient therapy services, the Balanced Budget Act of 2018 required that CMS institute a reduced payment rate of 85% of the otherwise applicable Part B payment for any therapy services provided in whole or in part by a therapy assistant (TA). The new payment rate will take effect on January 1, 2022, but the Act requires the use of a modifier to indicate TA involvement by January 1, 2020. Currently, there are three modifiers for outpatient therapy services — GP, GO, and GP — to distinguish therapy services provided under a Physical Therapy (PT) Occupational Therapy (OT) or Speech-Language Pathology (SLP) plan of care, respectively. CMS proposes that in addition to those current modifiers, providers will need to also begin including two additional modifiers when a TA provides the services in whole or in part. Specifically, the modifier CQ will need to be included in the claim line along with GP if a physical therapy assistant is involved in the services, and a CO modifier will need to be included along with GO when an occupational therapy assistant is involved in providing the services. CMS says that it does not believe there is speech-language therapy assistants or the equivalent, so it does not propose a SLP assistant modifier. CMS also proposes how to define when a TA is considered to have provided the services “in-part,” and thus trigger the need for the TA modifier. Originally, in last year’s proposed rule, CMS proposed that the standard would be that the modifier was to be used when the TA provided any single minute of the therapeutic portion of the service — which it elaborated would be any portion of the service that required the skills of a TA, as opposed to unskilled personnel. However, after receiving feedback from providers, including AMRPA, CMS now proposes what it refers to as the de minimis standard, which requires the modifier when 10% or less of the billed service is provided by the TA. To determine whether the more than 10% threshold is reached, CMS says providers should first determine the total therapy time provided. CMS proposes that the total time spent by the therapist should be the summation of the time the therapist provided alone, any time the therapist and TA provided together, and any time the TA provided
34 AMRPA Magazine / September 2019
alone. Under this method, CMS proposes that any time spent by the TA concurrently with the therapist is only counted once. Then, the time spent by the TA is divided by the total time. That number is then multiplied by 100. CMS then proposes providers round to the nearest whole number of that result. If the resulting figure is 11 or more, the modifier is required. Alternatively, CMS says providers could divide the total therapy time by 10, round to the nearest whole number, add one, and that is the total minutes required to trigger the modifier. The below table from the proposed rule provides some examples of these calculations. CMS next proposes how providers should apply the modifier when billing multiple units of the same procedure. This is necessary since many therapy service codes are defined as 15-minute increments and billed in multiple units for one session. CMS proposes that providers look at the total time provided for each service code billed and apply the above methodology to that billed service to determine if the 10% threshold is exceeded. In other words, even if the TA only participated in the first 10 minutes of services, and there were multiple 15-minute increment units billed, the modifier would still need to be applied, and will be applicable to all the units of the code, unless there were more than 100 minutes total of services provided for that particular code. CMS is also proposing that therapists be required to document in the medical record a brief justification for including, or not including, the modifier. CMS also seeks comment on whether therapists should be required to enter the exact number of minutes the TA provided, rather than just a statement to the effect that the TA minutes did or did not exceed 10%. CMS concludes by providing a number of illustrative example scenarios on how these proposed policies would apply to various situations. Physician Evaluation and Management (E/M) Visit Code Payment and Documentation Last year, CMS finalized significant changes to the Evaluation and Management (E/M) codes used by physicians and other
advanced practice clinicians to bill office and other outpatient visits (CPT Codes 99201-99205 & 99211-99215). These changes were finalized to go into place in 2021. Currently, a physician will bill one of five E/M codes for outpatient visits. There are currently two distinct set of the five codes for outpatient visits: one for new patients (99201-99205) and one for established patients (99211-99215). According to CMS, these E/M codes account for approximately 20% of all charges billed under the PFS. Practitioners currently determine which level of visit to bill based on guidelines from the American Medical Association (AMA). The AMA guidelines instruct physicians to choose one of the five levels based on a combination of three factors, including history of present illness (HPI), physical examination, and medical decision making (MDM). CMS also proposed and finalized last year that physicians be able to choose the visit level based on time. The level of code generally increases as time, resources or the complexity of the patient increases, with level 1 being the lowest and level 5 being the highest. There are unique payments for each of the ten codes, and payment increases as the level of the visit increases. CMS finalized last year that effective 2021, it will consolidate payment amounts for visit levels 2-4. According to CMS, this would allow for simplified documentation requirements, reducing burdens on clinicians billing these relatively similar visit levels. However, CMS is now proposing an entirely different approach to changing the current E/M codes. CMS now proposes to retain separate payment levels for all E/M levels. While there will remain separate payment amounts for all levels, CMS also proposes to adopt updated values for these codes from the AMA that would significantly increase the payment amount for these codes. CMS is also proposing to continue with changes that would alter how physicians choose which level to bill. Again adopting AMA recommendations, CMS proposes that physicians can choose the level of visit solely based upon the MDM involved, or solely based on the time involved. CMS proposes to eliminate the option of deciding visit level based on physical exam and the
AMRPA Magazine / September 2019 35
number of organ systems evaluated by the physician, which the agency says is outdated. Additionally, CMS proposes to eliminate level 1 visits for new patients, as those are rarely billed given the resources needed for evaluating a new patient. Given the proposed consolidation of E/M payment levels last year, CMS proposed in that rule add-on codes for physicians that may find themselves undercompensated for treating particularly complex or resources-extensive patients. Given that CMS is walking back its proposed consolidation of payment rates, it is also altering its proposed new add-on codes. It now proposes two distinct add-on codes. The first would be for prolonged services, when the time involved takes longer than the typical time for a level 5 visit. The second code would be a complexity add-on code, which would be used for primary care physicians devoting additional resources to services such as resources spent coordinating care; the second use of this code would be for specialists treating particularly complex patients. Finally, last year CMS adopted a reduced documentation threshold, so that physicians would only need to document at a level 2 level for all 2-4 level visits, consistent with the consolidated payment rate. CMS is no longer proposing to adopt that change. Instead, physicians will be required to provide documentation for the corresponding visit level, but only for the element used to justify the visit level, which would be either MDM or time. Chronic Care Management CMS is proposing several changes which will expand the ability of physicians to bill for management of patients with very complex conditions. First, CMS is lifting the restriction on physicians billing transitional care management (TCM) codes concurrently with other codes such as care plan oversight or complex chronic care management services. In addition, current chronic care management (CCM) codes are only available for patients with two or more chronic conditions. CMS is proposing a new CCM code that would be for patients with one complex condition or disease. In addition, CMS is proposing codes that could be billed by clinical staff working to coordinate complex care, thereby allowing for additional reimbursement. Physician Documentation Requirement Changes Last year, CMS eliminated its requirement that teaching physicians must re-document items that were already entered into the medical record by a nurse, resident or another physician. Now, CMS is proposing to expand this policy to all clinicians billing under Part B, and regardless of whether the clinician is acting in a teaching capacity. CMS proposes that any billing clinician will be permitted to enter a signed notation that they have reviewed the information entered by another individual, rather than re-document that same information. This would include documentation that the clinician was present for a certain time with the patient. Supervision and Scope of Practice of Physician Assistants In this proposed rule, CMS takes note of the many comments it has received stating that its current standards for supervision requirements for Physician Assistants (PA) is outdated. CMS
36 AMRPA Magazine / September 2019
therefore proposes to refine its current regulations, which apply a general supervision requirement for PAs billing services for Medicare beneficiaries. The agency also takes note that many states have recently changed its state laws to allow for greater autonomy for PAs. CMS now proposes that PAs must be supervised in accordance with the state law in which they practice, rather than a specific CMS standard. In the absence of a state law, providers must document the way in which the PA is supervised by medical staff for the services delivered. CMS says this proposal also would align the PA scope of practice in Medicare with those used by Nurse Practitioners. Other Proposals The lengthy rule also contains a number of other proposals, briefly summarized below: CMS requests information and suggestions on ideas on how to bundle PFS payments to lessen burden and improve care and payment processes. CMS proposes a number of new codes that would allow for reimbursement for non-face-to-face evaluations (digital evaluations) that require MDM. CMS proposes to establish regulations for the new congressionally created benefit for Opioid Use Disorder Treatment Services. CMS proposes a new bundled payment for substance use disorder treatment. CMS solicits comments on potential changes to the Stark Law advisory opinion process. CMS seeks comments on changes to the Medicare Shared Savings Program (MSSP), including better aligning the program with the Merit-Based Incentive Payment System (MIPS). The rule also contains yearly updates to the Quality Payment Program (QPP), which includes MIPS and Advanced Alternative Payment Models (AAPMs). Overall Payment Changes Overall, payments in the PFS must be proposed in budget neutral manner, so CMS does not estimate an overall change in payments for FY 2020. However, due to shifts in the relative values for services, and a small change in the standard conversion factor, CMS estimates overall payment changes by specialties. CMS estimates that there would be minimal overall change to both the physical medicine specialty and physical and occupational therapy specialty due to this year’s changes (both listed as an estimated 0% change). However, CMS also estimated what effect its proposed E/M coding changes, as described above, may have on each specialty. CMS estimates that if the E/M proposals took effect in 2020, physical medicine specialists would see a 2% decrease in payments, and physical and occupational therapists would see an 8% reduction in payments.
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AMRPA Magazine / September 2019 37
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38 AMRPA Magazine / September 2019
Don’t Miss Out on a Full Day of Education and Mentorship at AMRPA’s IRF Boot Camp! // This pre-conference Boot Camp will provide rehabilitation managers and medical directors of rehabilitation programs with the fundamental knowledge needed before entering the three days of concurrent educational tracks at the Educational Conference & Expo.
AMRPA will host its second annual inpatient rehabilitation facility (IRF) Boot Camp on October 13 in San Diego. The IRF Boot Camp will take place the day before the 2019 AMRPA Fall Educational Conference & Expo, and AMRPA is excited to offer a revamped Boot Camp to provide attendees with a full day of mentorship and education. The IRF Boot Camp is designed for administrators, managers and physicians of inpatient rehabilitation hospital programs. And although it is specially developed to meet the educational needs of those new to the medical rehabilitation field, the content will also be helpful for those with different levels of experience and roles in rehabilitation hospitals/ units.
Registration Now Open!
This pre-conference Boot Camp will provide rehabilitation managers and medical directors of rehabilitation programs with the fundamental knowledge needed before entering the three days of concurrent educational tracks at the Educational Conference & Expo. Attendees will not only understand the rules and regulations that guide IRFs, but how to apply them to your day-to-day operations. Learn how to cut through the myths about inpatient rehabilitation, document properly, and improve your overall quality of care while expanding patient access to IRF services from our group of experts. Don't miss out – visit the AMRPA website to register today!
Visit: AMRPA.org/2019-Fall-Conference-Registration
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What Should You Know About the AMRPA IRF Boot Camp? AMRPA spoke with Bob Bianchi, Senior Director of Rehabilitation for Tenet Healthcare and Program Chair of the IRF Boot Camp, to get more information on this year’s program. What can attendees expect from the IRF Boot Camp? Firstly, attendees can expect a concentrated, comprehensive review of the success factors that are important for the day-to-day operations of an inpatient rehabilitation hospital program. Secondly, attendees are going to get practical, operational guidelines on how to apply these key success factors into each of their programs. Lastly, what any manager faces, whether they are brand new or seasoned, are any series of myths about how a program should operate. One of our unwritten agenda items is to make sure that we are busting these myths so that people can evaluate if their program is operating truly to the rules or just in the way they always have.
AMRPA Magazine / September 2019 39
How will this IRF Boot Camp be different from last year’s? This year’s program has been expanded to a full day and we intend to use that time by delving further into the referral development process so that managers understand the best practices of building volume. Additionally, we’re going to dig deeper into the role of the medical director so that whether you’re a manager or a medical director yourself, we can talk about the issues and challenges facing that key position. What skills or knowledge will attendees walk away with? Attendees, whether new or seasoned, will get a key understanding of the best practices for referral development, a terrific understanding of documentation strategies as they apply to the CMS rules, and ideas on furthering the distinction of their program through program development strategies. Even seasoned managers who have been in their role for a long period of time seem to benefit from this terrific refresher. The interchange between participants on key questions on their mind and having a forum to exchange best practices is a very valuable aspect of the Boot Camp.
40 AMRPA Magazine / September 2019
Who will benefit most from the Boot Camp? While it is somewhat built for the novice rehabilitation manager, we find that other participants benefit as well and those include: the therapy director or nurse manager who would like to have knowledge to help advance their career towards a higher position; medical directors who have been in their role for a year or so benefit from hearing the Medicare rules in a comprehensive manner; and third, managers who have a program that seems to be not performing as well as it could. This Boot Camp allows them to hear in a comprehensive way the basics they need to adhere to so that they can adjust their program accordingly for success. How did you select the speakers? I find that it is best to have speakers who know how to present information that keeps an audience engaged in what they have to say. So not only did we look for speakers with terrific experience, we sought people who are subject matter experts and are dynamic speakers who can hold an audience’s attention. *** The IRF Boot Camp is a program full of essential information that will help attendees improve their inpatient rehabilitation programs. For more information and to register, visit the IRF Boot Camp webpage.
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AMRPA Magazine / September 2019 41
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www.movendo.technology 42 AMRPA Magazine / September 2019
AMRPA Successfully Relaunches Regional Meetings Series
This summer, AMRPA reinstituted its Regional Meeting Series in Grand Rapids, Michigan, and Jacksonville, Florida, to bring AMRPA staff and educational resources directly to members’ doorsteps. The Regional Meetings offered opportunities to network with other professionals in the area, provided updates on AMRPA legislative, regulatory and operational issues, and offered continuing education credits. At both meetings, AMRPA staff gave a legislative and regulatory update and provided information on the Centers for Medicare and Medicaid Services (CMS) federal fiscal year 2020 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) proposed rule. With the conferences occurring during the rule’s comment period, the sessions provided a great opportunity for AMRPA to hear some of the key questions and concerns from our members and to discuss the Association’s analysis of and response to major issues in the proposed rule. In both conferences, attendees engaged with AMRPA staff to learn more about the Association’s Congressional advocacy efforts and legislative initiatives in the 116th Congress. The first Regional Meeting was hosted by Mary Free Bed Rehabilitation Hospital in Grand Rapids, Michigan, on June 7. The night before the meeting, a reception for attendees was held at the Grand Rapids Art Museum. sixty-three medical rehabilitation professionals, a mix of both AMRPA members and non-members, attended the meeting. Speaker sessions covered various topics including how to prepare for the IRF PPS case-mix group changes, workforce recruitment and retention, using virtual technology to optimize patient access, as well as regionally-targeted content. After the education sessions, attendees were able to take a tour of Mary Free Bed Hospital. The second Regional Meeting was held in Jacksonville, Florida, on June 14 and was hosted by Brooks Rehabilitation Hospital, with an opening reception the night before in downtown Jacksonville. The meeting had 60 attendees who were a mix of AMRPA members and non-members. Speaker sessions covered emerging technologies in rehabilitation, the role of community-based programs in long-term patient recovery, and advocating for the IRF level of care in communities, among others. Throughout the conference, attendees were able to tour the Brooks Rehabilitation Hospital facilities. Sponsors at the Regional Meetings included Encompass Health, Gorbel, Hope Network Neuro Rehabilitation and WellSky.
AMRPA Magazine / September 2019 43
Select sessions from the Regional Meetings have been turned into AMRPA webinars, so be sure to check the AMRPA website for access to the educational content. Be on the lookout for AMRPA’s 2020 Regional Meetings, expected to be announced early next year!.
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CRITICAL CARE PHYSICAL MEDICINE AND REHABILITATION PROGRAM Featured Speakers
Register Now!
Dale Needham, FCPA, MD, MBA
8th Annual Johns Hopkins Critical Care Rehabilitation Conference The Johns Hopkins Hospital, Baltimore, MD Oct. 10-12, 2019
Michael Friedman, PT, MBA
Foundations/Pre-Conference (Oct. 10) Adult ICU Rehabilitation Foundations Pediatric ICU Rehabilitation Foundations Combating the Hospital Immobility Harm Foundations Recovery of the Critically Ill Patient in Post-ICU Settings
Annette Lavezza, OTR/L
Main Conference (Oct. 11 & 12) Patient and Family Perspectives Separate Tracks for Adult and Pediatric ICU Rehabilitation Updates on the Latest Literature for Evidence-Based Practice Workshops on Topics in Adult and Pediatric ICUs, Culture Change, and Hospital-Wide Activity and Mobility Promotion
Sapna Kudchadkar, MD, PhD
Julie Quinn, PT, MSEd, PCS
For more information, please visit: hopkinsmedicine.org/oacis/icurehab | @icurehab | icurehab@jhmi.edu
AMRPA Magazine / September 2019 45
Spring Conference
& Congressional Fly-In
Watergate Hotel • Washington, DC
Save the Date March 22-24, 2020 amrpa.org/spring-2020
46 AMRPA Magazine / September 2019
Study Examines Relationship Between Hospital-based Rehabilitation Services and Hospital Readmission Following Ischemic Stroke
Highlight: »»
Increased amounts of hospitalbased rehabilitation services were linked to lower risks of rehospitalization.
For stroke patients, rehabilitation treatment early in the care process is crucial for achieving improvement of patients’ functional status outcomes. A study in the Archives of Physical Medicine and Rehabilitation assessed the association between hospital-based rehabilitation and hospital readmission following ischemic stroke. The researchers note that there is limited evidence supporting the role of rehabilitation services in patient outcomes in acute-care settings, even though earlier rehabilitation intervention results in better longer-term functional gains. The objective of this study was to examine the relationship between hospital-based rehabilitation services and 30-day hospital readmission among patients with ischemic stroke using a more detailed methodological approach than had been used in past studies. Researchers conducted a secondary analysis of inpatient Medicare claims data of acutecare hospitals in the United States. The data was sourced from the Medicare inpatient 100% claims data using Standard Analytical File, Provider of Services File, Master Beneficiary Summary File, and Chronic Conditions Warehouse data. The participant sample was limited to older Medicare beneficiaries (66 years of age or older) on a feefor-service (FFS) plan with ischemic stroke who were admitted to hospitals after January 1, 2010 and discharged by November 30, 2010. The researchers conducted an analysis for the impacts of both physical therapy and occupational therapy on readmission rates for patients with ischemic stroke. With regard to study limitations, the researchers note that the study does not control for stroke severity or functional status, and the study’s analytical model also did not account for post-acute care setting selection bias. Findings The study found that 14% of participants were re-hospitalized within 30 days following discharge from an acute-care hospital. Individuals who were re-hospitalized were more likely to be Black, older and eligible for Medicare-Medicaid dual enrollment with a higher number of chronic conditions and a longer length of stay. Researchers observed that the greater amount of physical therapy services provided, the lower the chances of readmission compared to patients who received no therapy services. The researchers did not identify a correlation between occupational therapy services and risk of rehospitalization. An association between post-acute care setting and the risk of readmission was also identified. Researchers found that patients treated at skilled nursing facilities (SNFs) were the most likely to be readmitted, followed by inpatient rehabilitation facilities (IRFs). However, patients that were treated at a hospital with an IRF unit had a lower
AMRPA Magazine / September 2019 47
risk of readmission. Patients discharged home with home health (HH) services were the least likely to be re-hospitalized. The study did not account for the severity of the ischemic stroke or patient characteristics such as functional ability. Conclusions This study found a strong, positive relationship between an increased use of hospital-based rehabilitation and a decreased rate of 30-day re-hospitalization following ischemic stroke, which was consistent with the researchers’ hypothesis. The researchers cite two main reasons to support the association between rehabilitation and readmission rates. First, occupational and physical therapists have important roles in addressing a patient’s functional status, which is a very robust predictor of readmission. Second, occupational and physical therapists also have a critical role in the discharge planning process and preparing beneficiaries for the next level of care.
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The researchers note that the finding that patients who receive care from an IRF unit within a hospital have lower rates of readmission is consistent with previous studies examining the impact of hospital-IRF integration on patient outcomes, as the integration allows for a smoother exchange of the care plan and important clinical information. The researchers concluded that the results of this study add to the existing evidence demonstrating the value of rehabilitation in lowering the likelihood of readmission following ischemic stroke. For the full study, see Use of Hospital-Based Rehabilitation Services and Hospital Readmission Following Ischemic Stroke in the United States, Kumar, Amit et al., Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 7, 1218 – 1225.
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AMRPA Magazine / September 2019 49
HHS OIG Publishes Report Examining Accountable Care Organizations’ Strategies for Transitioning to Value-Based Care Highlights: »»
»»
HHS OIG examined various strategies ACOs use to realize savings for the Medicare program and shift towards value-based care. OIG’s key recommendations include better sharing of best practices among ACOs and the adoption of outcome-based quality measures.
In late July, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a report, ACOs’ Strategies for Transitioning to Value-Based Care: Lessons From the Medicare Shared Savings Program. The report took a close look at various strategies employed by Accountable Care Organizations (ACOs) to increase savings for the Medicare program while shifting towards value-based care. The Medicare Shared Savings Program (MSSP) is one of the Centers for Medicare and Medicaid’s (CMS) largest alternative payment models (APM) that reward providers for value and quality of services provided. The program allows providers to voluntarily form ACOs to coordinate patient care in an effort to improve quality of care and reduce costs. OIG conducted this review so the findings could inform current and future ACOs, as well as other APMs. For this report, OIG reviewed of a sample of 20 high-performing ACOs that were successful in decreasing Medicare spending while providing high-quality care to beneficiaries. OIG defined “high-performing ACOs” as those that had both a reduction in spending relative to their benchmark and an overall quality score of 90 or above during their second, third or fourth program performance year. The OIG interviewed officials from each ACO and analyzed supplemental documents provided by the organizations. The report finds that ACOs find success when implementing strategies from the following categories. OIG recommended that CMS use these strategies to inform the agency’s broader efforts to transition to value-based care: 1. W ork with physicians The report found that working with physicians was essential to successfully lowering costs and improving quality of care. Strategies mentioned in the report include recruiting physicians with a commitment to ACO goals, providing physicians with cost information on their practices and referrals to specialists, and providing physicians with information on gaps in care and quality measures. 2. Engage beneficiaries ACOs have found that, while it can be challenging, engaging beneficiaries to take an active role in their health can lead to better care and outcomes. In particular, the report notes that increasing wellness visits and educating beneficiaries on health care topics improve patient engagement. 3. Manage beneficiaries with complex or costly needs Recognizing that beneficiaries with complex needs make up a significant portion of total health care spending, ACOs have found that using care coordinators to manage
50 AMRPA Magazine / September 2019
beneficiaries’ health and providing care outside of the physician office help to mitigate those costs while still providing quality care. 4. I mprove hospital care and reduce avoidable hospitalizations ACOs have employed some of the following strategies to reduce costly and avoidable rehospitalizations: expanding access to primary care services, improving care coordination within hospitals and at hospital discharge, and targeting frequent users of emergency room services. 5. C ontrol costs and improve quality in skilled nursing facilities (SNFs) and home health agencies (HHAs) ACOs face challenges when trying to manage SNF and HHA services, as those providers are not usually part of the ACOs. In order to address this challenge, ACOs have found success by designating certain SNFs and HHAs as preferred providers, employing staff in SNFs to monitor beneficiaries’ health, and encouraging primary care providers to more closely examine care needs. 6. A ddress social determinants of health and behavioral health needs ACOs encounter challenges when addressing beneficiaries’ behavioral health needs and social determinants of health, often due to a lack of behavioral health care providers or limited data to identify those beneficiaries who need behavioral health services. To ameliorate these challenges, ACOs have been recruiting behavioral health providers, integrating physical and behavioral health care into primary care settings, and using data to identify beneficiaries with behavioral health needs. Regarding social determinants of health, ACOs have found success incorporating non-medical staff into practices to address unmet social needs, and by providing resources to targeted beneficiaries most likely to have unmet social needs.
beneficiaries’ health records from other providers, information that is helpful when coordinating care across different settings. To address this problem, ACOs have started using one electronic health record (EHR) system, developing alternative systems to communicate with ACO providers, and using state and regional data systems to communicate with providers outside of their ACO. To help ACOs meet their goal of improving quality of care while reducing Medicare costs, OIG recommended that CMS take the following actions: 1. Review the impact of programmatic changes on ACOs’ ability to promote value-based care. 2. Expand efforts to share information about strategies that reduce spending and improve quality among ACOs and more widely with the public. 3. Adopt outcome-based quality measures and better align measures across programs. 4. Assess and share information about ACOs’ use of the SNF 3-day rule waiver and apply these results when making changes to the Shared Savings Program or other programs. 5. Identify and share information about strategies that integrate physical and behavioral health services and address social determinants of health. 6. Identify and share information about strategies that encourage patients to share behavioral health data. 7. Prioritize ACO referrals of potential fraud, waste, and abuse. CMS concurred with all of OIG’s recommendations, and a full text of CMS’ comments can be found in Appendix B of the OIG report. The full HHS OIG report is available at www.oig.hhs.gov.
7. Use technology to increase information sharing between providers ACOs reported that they do not always have access to
AMRPA Magazine / September 2019 51
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