AMRPA December 2018 Magazine

December 2018 • Vol. 21, No.12

AMRPA: Advocating for Patients and Providers

December 2018 • Vol. 21, No. 12

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 Carolyn Zollar, MA, JD AMRPA Executive Vice President for Government Relations and Policy Development Mimi Zhang AMRPA Senior Policy and Research Analyst

Table of Contents Letter from the Chair

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Legislative Update

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HHS Implements IRF Coverage and Appeals Changes

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The Middle of the IRF-PAI

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MedPAC to Examine Post-Acute Care Functional Assessment Data

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AMRPA Submits Comments on Medicare Accountable Care Organizations Proposed Rule

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AMRPA Submits Comments on Reforming Anti-Kickback Regulations

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CY 2019 Home Health Rule Finalizes New Payment Model For 2020

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Patricia Sullivan AMRPA Senior Editor

Robotic Arm May Help Rehabilitate Chronic Stroke Victims

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Lovelyn Robinson AMRPA Researcher and Editor

CMS Releases Nursing Home Compare Quality Reporting Program Data 27

Brian McGowan AMRPA Design and Layout

Physician Practices Joining Early ACOs Were Large and Capable, but Performance was Modest

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AMRPA Magazine, Volume 21, Number 12

Disparities in Readmission Rates Between Patients Discharged from Safety-Net or Non-Safety-Net Hospitals

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New Therapy Technique Doubles Movement Recovery in Stroke Patients

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Study Examines the Association Between Patient Outcomes and Accreditation

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Latest Research Findings

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AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA).

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

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by American Medical Rehabilitation Providers Association.

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AMRPA Magazine / December 2018

Letter from the Chair

AMRPA: Advocating for Patients and Providers By now most of you may be aware of the recent report, Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements (Department of Health and Human Services, 2018). This report was prepared by the Office of Inspector General (OIG) within the Department of Health and Human Services (HHS). AMRPA is actively analyzing the report and working with other advocacy groups, such as the American Academy of Physical Medicine and Rehabilitation, in order to address findings from the report.

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

AMRPA has many questions about the report including its recommendations. At the time of this writing, we do not have access to the data from the selected 2013 cases upon which the report is based. Without this fundamental information, we are unable to properly assess the study.

We have formed an AMRPA OIG Report work group to assess all aspects of the report.

Once we can access the data, we will also seek the support of our members for the medical records that formed the basis of the report. Then we will be better able to assess the OIG’s recommendations and create a fully vetted response.

In addition to the OIG study, other issues have been heating up. HHS has begun exploring the development of a unified post-acute care prospective payment system (unified PAC PPS) as mandated by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. HHS held an initial technical expert panel (TEP) on this subject. AMRPA was invited to participate on the panel and was well-represented by Suzanne Snyder Kauserud, vice president of Carolinas Rehabilitation and a member of the AMRPA Board. She is also chair of a newly formed AMRPA unified PAC PPS workgroup and chair of the AMRPA Quality Committee. We hope that our new, unified PAC PPS workgroup will examine the issues raised by the TEP as well as future matters that will arise related to a unified payment system.

As the unified PAC PPS is considered, we look forward to working with our members to ensure that we can develop meaningful comments and recommendations. We hope to engage our membership on various aspects of the unified PAC PPS over time. If you have any specific question or interests in this workgroup, please do not hesitate to reach out to AMRPA Executive Vice President for Policy Development and Government Relations Carolyn Zollar (czollar@amrpa.org), and AMRPA Senior Policy and Research Analyst Mimi Zhang (mzhang@amrpa.org).

Lastly, by the time of this magazine’s publication, we will have learned the results of the midterm elections and we should have a better understanding of the legislative and regulatory environment facing us. While there are difficult issues to address, we are stronger together and your voice is needed more today than ever. Please don’t hesitate to reach out.

REFERENCE Department of Health and Human Services Office of Inspector General. (2018, September). Many inpatient rehabilitation facility stays did not meet Medicare coverage and documentation requirements (report number A-01-15-00500). https://oig.hhs.gov/oas/reports/region1/11500500.pdf.

AMRPA Magazine / December 2018

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Save The Date

2019 Spring Conference & Congressional Fly-In March 10-12, 2019 • Ritz Carlton Pentagon City Hotel • Arlington, VA

Legislative Update

Federal Election Recap 2018 As many political pundits projected, the Democrats came out on top in the House elections. Current Democratic Leader Nancy Pelosi (D-CA) is expected to assume the Speaker’s role in the House. In Congress, Republicans presently hold the House majority with 235 seats. The Democrats have 193 seats, and there were seven vacancies headed into the election.

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

Highlights: »»

Democrats win back the House of Representatives in the 2018 mid-term elections, but Republicans increase their majority in the Senate.

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CMS released several final payment policies including the CY 2019 the Home Health Prospective Payment System (HHPPS), which establishes a new home health payment system set to begin in 2020.

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The CY 2019 Medicare Physician Fee Schedule (PFS) Final Rule includes policies aimed at increasing Medicare beneficiary access to remote physician services.

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CMS issued a proposed rule regarding policy and technical changes to the Medicare Advantage (MA) and Part D programs.

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HHS announced a proposed new “International Pricing Index” (IPI) payment model estimated to save Medicare $17.2 billion over five years.

As we go to print, Democrats have already flipped 29 seats currently held by Republicans while the GOP captured two seats from Democrats, leaving Democrats with a net gain of 27 thus far. When the 116th Congress convenes in January, the Democratic Party will hold more than 220 seats, returning the party to power for the first time in eight years. Both parties could see their seat totals rise as victors in 14 seats remain undetermined. Current Health Subcommittee Chair Peter Roskam (R-IL-6) lost his race, along with fellow Committee Members Reps. Curbelo (R-FL-26), Paulsen (R-MN-03), and Bishop (R-MI-08). It is expected that Ranking Member Richard Neal (D-MA-1) will lead the Committee in the 116th Congress and Rep. Lloyd Doggett (D-TX) is expected to chair the Committee’s Health Subcommittee. The House Energy and Commerce Committee will also see some change in the new Congress, mostly due to several Republican member retirements. Current Ranking Member Frank Pallone (D-NJ6) is expected to take the Committee gavel again.

Only 35 seats were in cycle in the Senate this year. Going into the election, Republicans held a slim majority with 51 seats, and Democrats and Democratic-caucusing Independents held 49 seats. As of writing, the GOP defeated three sitting Democratic Senators in Indiana, Missouri and North Dakota. Republicans lost a seat in Nevada, bringing their current total for the new Congress back to 51. At this time, Republicans are leading in four other races that have yet to be called (including a special election in Mississippi that will result in a runoff), leaving President Trump’s Senate contingent with the possibility of picking up more seats. It remains to be seen whether former Senate Finance Committee Chair Charles Grassley (R-IA) will lead the Committee (he would have to step down as Judiciary Committee Chair) or allow the next Republican in line, Rep. Mike Crapo (R-ID) to be the chair. Finance Committee member Sen. Dean Heller (R-NV) lost his bid for re-election, as did Sen. Claire McCaskill (D-MO).

On the gubernatorial side, Democrats were successful in picking up governorships now held by Republicans in Kansas, Illinois, Michigan, New Mexico, Maine and Wisconsin, bringing their total to 23. Republicans picked up the Alaska governorship, and currently lead Democrats with 26 state chief executives, including Florida and Ohio. As we go to print, the Georgia election has not yet been called.

With Democrats in control of the House, the 116th Congress is expected to sharpen its focus on health care access and consumer costs in 2019. In particular, a Democratic

AMRPA Magazine / December 2018

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House is likely to advance drug pricing legislation, though it is unclear whether calls for more drastic reforms will be successful.

It also remains unclear whether Democrats will help the Administration advance its own drug pricing agenda; however, bipartisan support exists for legislation to address "surprise" costs to consumers through balance billing of medical expenses for which they lack coverage. Republican efforts to repeal the Affordable Care Act (ACA) featured prominently in Democrats’ campaign messaging. A Democratic House will advance legislation to shore up the health law and stabilize insurance markets, and it also is expected to pass legislation to protect individuals with pre-existing conditions, while courts consider a challenge to the ACA filed by 20 Republican Attorneys General. However, the likelihood of a Democratic-controlled House seeing any of its legislation become law is dubious, but it could effectively block the Administration’s push for funding a border wall, further unraveling of the ACA or cuts to entitlement programs, such as Medicaid.

With control of House Committees and related subpoena power, oversight will be a top priority for Democrats, and they are likely to focus on both the Trump Administration’s efforts to derail the ACA and pharmaceutical manufacturers’ pricing practices.

Democrats' success in securing a majority in the House was also accompanied by electoral victories at the state level. As a result of ballot initiatives and gubernatorial victories, several additional states now are expected to expand coverage under Medicaid.

Finally, the current suspension of the debt ceiling will expire in March 2019. Negotiations around an increase in the debt limit could prompt members to push for a broader budget and deficit reduction package, which could pose a risk to health care provider payments.

CMS Proposes MA Changes On October 26, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule regarding policy and technical changes to the Medicare Advantage (MA) and Part D programs. CMS is proposing to implement several sections of the Bipartisan Budget Act of 2018 (BBA), including allowing MA plans to offer additional telehealth benefits. The proposed rule updates the Medicare Advantage and Part D Prescription Drug Plan Quality Rating System and would also revise the appeals and grievances requirements for Medicaid managed care and MA special needs plans for dually eligible individuals to implement certain provisions of the BBA. Final HH PPS Rule Moves Forward with Patient-Driven Grouping Model On October 31, CMS released the Home Health Prospective Payment System (PPS) Final Rule and despite pushback from stakeholders finalized implementation of the Patient Driven Groupings Model (PDGM), beginning in 2020. This is a drastic change to how home health agencies are reimbursed and will require major adjustments in order to remain viable under the reformed system. Stakeholders specifically objected to the behavioral adjustments included in the model, but CMS defended the adjustments in the Final Rule and noted that 2020 payment amounts have not yet been set. PDGM would also amend the current unit of payment of 60 days to a 30-day unit

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of payment, and aims to remove the incentives to over-provide therapy and focus on patient clinical characteristics to ensure a more data-drive and value-based approach to home health care. The Final Rule also finalizes the definition of remote patient monitoring for home health, which can now be included as an allowable cost on cost reports. CMS estimates that payments to home health agencies will increase by 2.2 percent, or $420 million in CY 2019.

2019 Physician Fee Schedule Rule Expands Access to Remote Physician Services On November 1, CMS published the calendar year (CY) 2019 Medicare Physician Fee Schedule (PFS) Final Rule. CMS made changes to its proposal to consolidate the E/M codes into new, single blended payment rates for new and established patients.

In the Final Rule, CMS preserves the billing codes for the most complex patients and delays collapses the coding system into three tiers until 2021. Specifically, CMS will phase-in several changes related to payment, coding, and documentation of evaluation and management (E/M) office visits, including a single, blended rate for visit levels 2 through 4 beginning CY 2021.

Although providers appreciated the agency’s efforts to reduce administrative burden, there was tremendous concern from the specialty community that reimbursement for treating complex patients would be greatly reduced.

In the Final Rule, CMS elected to phase-in several changes related to payment, coding and documentation of evaluation and management (E/M) office visits, including a single, blended rate for visit levels 2 through 4 beginning CY 2021. For CY 2019, CMS finalized policies to reduce duplicative documentation.

Practitioners will continue to use the 1995 or 1997 versions of the E/M guidelines that they use today. Beginning in CY 2021, CMS will establish a single/blended payment for levels 2 through 4, instead of its original proposal to collapse levels 2 through 5. This policy may produce a modest reduction in payment for specialists who frequently use E/M codes. CMS will also implement a number of policies aimed at reducing administrative burden and improving payment accuracy for E/M payments, such as allowing practitioners to use time, medical decision-making, or the 1995 or 1997 guidelines to document visits.

Additionally, the Final Rule includes policies aimed at increasing Medicare beneficiary access to remote physician services.

The Final Rule includes policies to: (1) provide payment for communication via technology-based services (e.g., virtual interaction, review of recorded videos/images forwarded to a physician); (2) add new codes for chronic care remote physiologic monitoring and interprofessional consultations over the internet; and (3) add codes for prolonged preventative services to the list of telehealth services.

The Final Rule also included changes to the Quality Payment Program (QPP) for CY 2019, which requires physicians and other professionals to report quality measures that impact their reimbursement under the PFS. CMS expands the cost performance category, which will increase the overall importance of their resources use when adjusting their reimbursement.

New Drug Pricing Model On October 25, CMS released an advance notice of proposed rulemaking to solicit comments on testing payment changes for certain Part B drugs and biologicals. CMS intends to issue a proposed rule in the spring of 2019 to announce its plans to establish an International Pricing Index (IPI) model. Comments are due on the notice by Monday, December 24, 2018.

The proposed IPI model aims to: reduce Medicare spending and beneficiary cost-sharing for separately payable Part B drugs; preserve or enhance quality of care for beneficiaries; offer comparable pricing relative to international markets; remove incentives for providers to prescribe higher-cost drugs; minimize disruption to the current supply chain; and increase Medicare efficiency and value.

As currently proposed, the IPI model would set the Medicare payment amount for selected Medicare Part B drugs at a target price more closely aligned with international prices, and to phase down payment to that price over a five-year demonstration period (i.e., year 1: 80 percent ASP / 20 percent target price; year 2: 60 percent ASP / 40 percent TP; etc.). Select geographic areas across the country would be required participate in the model, and mandate that all physicians, hospital outpatient departments (HOPDs), and potentially other health care providers obtain all applicable Part B drugs through the vendors as opposed to buying-and-billing Medicare directly. Participants would contract with private-sector vendors to negotiate prices for the applicable Part B drugs, assume the financial risk associated with the target price, and compete for physician and hospital business.

Participating health care providers would receive an add-on payment (based on 6 percent of historical drug costs) to offset the lost revenue from buy-and-bill without incentivizing the use of high-cost drugs. As currently planned, the IPI model would start in spring 2020 and operate for five years.

The midterm elections results will help us strategize for the new congressional session that will commence in 2019. The House and Senate reconvene for the Lame Duck session on November 13, and will initially focus on leadership elections and committee assignments. They will be pressed to deal with a December 7 deadline for funding the federal government.

The current Continuing Resolution (CR) will either need to be extended or Congress needs to finalize the remaining FY 2018 appropriation bills. With Democrats in control of the House next Congress, Republicans may pursue a conservative package of bills in the Lame Duck session, which could include: repeal of the ACA’s employer mandate or further delay of other ACA taxes (e.g., medical device and/or Cadillac taxes); tax reform “2.0”; tax extenders; drug pricing and transparency legislation; supplemental disaster funding; and other lower-tier Medicare and health bills, including possible additional “Red Tape” reduction initiatives. The Senate and House are scheduled to adjourn in mid-December with the 116th Congress set to begin on January 3, 2019.

AMRPA members should be ready to take action in these final weeks of 2018. Lame duck sessions in Congress can be wild and unexpected legislation considered. We remain concerned about the release of an unflattering OIG report, therefore, we encourage AMRPA rehab hospitals to take time to educate Congressional Representatives about how critically important and medically necessary rehabilitative care is for its patients. Now is the moment to reach out to your newly elected Members and ask them to visit your hospitals and outpatient facilities. Please cultivate strong Congressional champions for the field!

AMRPA Magazine / December 2018

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HHS Implements IRF Coverage and Appeals Changes

Over the past several months, the U.S. Department of Health and Human Services (HHS) has rolled out three major revisions to various agency manuals. First, the Centers for Medicare and Medicaid Services (CMS) issued two revisions to its Program Integrity Manual—memorializing the Targeted Probe and Educate (TPE) program and making substantial revisions to the procedure for creating Local Coverage Determinations (LCDs). In addition, the Office of Medicare Hearings and Appeals (OMHA) continues to implement new chapters in its Case Processing Manual.

Peter W. Thomas, Principal, and Ronald S. Connelly, Principal, The Powers Law Firm

While there are not any groundbreaking developments included in these revisions and new releases, the subject matter remains important to the inpatient rehabilitation field in light of continued audits, the re-emergence of the Recovery Auditors (formerly referred to as “RACs”) as a potential threat, and ongoing delays in resolving appeals through the administrative appeals system. For these reasons, we have summarized many of the key portions of the new and revised manual provisions in this article.

CMS Program Integrity Manual Revisions On August 17, 2018, CMS issued Transmittal 819, which creates new provisions within Chapter 3 of the Program Integrity Manual (PIM) covering the TPE process for medical review. Much of the information formally memorialized in the PIM is already common knowledge, since the TPE program was implemented nationwide in July 2017. Given the lapse of time between rollout of the TPE and this publication, it is easy to miss the significance of the new manual provisions. What the inclusion of the TPE provisions in the PIM likely means is that the TPE program is here to stay.

The TPE program encompasses both pre- and post-payment claims that are eligible for review. Typically, 20 to 40 claims per provider are selected for review, with up to three rounds of audits and intervening education. Providers are targeted for review based on historically high claim denial rates, billing practices that vary from peers, or when other evidence suggests a risk to the Medicare program. Failure to respond to a TPE request for records can result in immediate referral for investigation by a Recovery Auditor or a Universal Program Integrity Contractor (UPIC).

At the conclusion of each round of auditing, the Medicare Administrative Contractor (MAC) carrying out the TPE program must offer one-on-one “education” to the provider. The education can take the form of teleconferences, face-to-face sessions or webinars. Furthermore, if the MAC identifies an easily curable error, the provider is supposed to be notified and given the opportunity to address the problem (i.e., through submission of additional documentation). Finally, providers are to be given a minimum of 45 days following education before the next round of TPE reviews begins in order to allow the provider to implement necessary changes to its procedures.

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Anecdotal evidence suggests that TPE audits with education create a more equitable situation for IRF providers than random audits. However, there are concerns that there is no neutral third party to resolve disputes in coverage interpretation when the MAC simply disagrees with the front-line physicians and rehabilitation professionals who provide IRF care.

In addition to the inclusion of the TPE program within the PIM, CMS also announced major revisions to Chapter 13 of the manual, covering the LCD process. In Transmittal 829, issued on October 3, 2018, CMS responded to stakeholder feedback and requirements under the 21st Century Cures Act to revise the process for developing new LCDs. CMS acknowledged stakeholder concerns about the transparency and effectiveness of the previous process for developing LCDs and for notifying stakeholders of proposed changes and effective revisions to existing LCDs. As noted, CMS also is acting in accordance with the new requirements under § 1862(l)(5)(D) of the Social Security Act, which require MACs to post LCDs on their website (and on the CMS Medical Coverage Database) at least 45 days prior to their effective date. The website postings must include the following information: The LCD in its entirety; Where and when the proposed determination was first made public; Hyperlinks to the proposed determination and a response to comments submitted to the contractor with respect to such proposed determination; A summary of evidence that was considered by the contractor during the development of such determination and a list of the sources of such evidence; and An explanation of the rationale that supports such determination.

These steps will increase the transparency of the LCD process and raise the likelihood that LCDs are based on evidence.

Prior to publishing a final LCD, other steps of the new process also must be followed. During the development of a new LCD, the MACs are instructed to supplement their research with clinical guidelines, consensus documents, and consultations by recognized experts in the applicable field(s), medical associations, or other health care professionals for an advisory opinion. Then, once a draft LCD is created, it shall be published by the MAC for public comment. The MAC is to provide a minimum of 45 days for comment.

After the proposed LCD is made public, the MAC is to hold open meetings to discuss the evidence and rationale for the proposed LCD. Interested parties are permitted to make presentations, but all formal comments must be submitted in writing. The MAC is required to record the open meeting and maintain it as part of the administrative record. The MAC is also required to respond to all comments received during the comment period, which is to be made publicly available. The proposed LCD must be finalized (or else retired) within 365 days of its publication.

// The CAC is to be composed of health care professionals, beneficiary representatives, and representatives of medical organizations. All CAC meetings are to be open to the public and recorded.

Certain portions of CAC meetings may be closed, such as discussions of evidence for proposed LCDs.

The proposed LCD must include a summary of the opinions received as a result of any consultations, any recommendations from the Contractor Advisory Committee (CAC, as discussed in more detail below), and the evidence that supports the conclusions of the LCD. Specifically, the summary of the evidentiary content should include: A complete description of the item or service under review; A narrative that describes the scientific evidence supporting the clinical indications for the items or service; The target Medicare population; and Whether the item or service is intended for use by health care providers or beneficiaries.

The evidence that should be examined includes evidence of general acceptance by the medical community, such as published original research in peer-reviewed medical journals, systematic reviews and meta-analyses, evidence-based consensus statements, and clinical guidelines. All articles and sources shall be listed in the LCD in a bibliography.

One major area of stakeholder feedback that the new manual addresses is the composition and processes of the Contractor Advisory Committee. In response, the manual now requires the MAC to establish either (1) one CAC per state or (2) one unified CAC for the jurisdiction with at least one representative from each state. The CAC is to be composed of health care professionals, beneficiary representatives, and representatives of medical organizations. All CAC meetings are to be open to the public and recorded. Certain portions of CAC meetings may be closed, such as discussions of evidence for proposed LCDs.

These improvements in the LCD development process are vast improvements from the current system.

AMRPA Magazine / December 2018

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OMHA Case Processing Manual Between July and September, OMHA released several new chapters of its Case Processing Manual covering representatives, contractor roles, adjudication time frames, and scheduling of hearings. The audience for the manual is the Administrative Law Judges (ALJs) and their staffs, but the information is also instructive for appellants. Most of the information is already included in the regulations covering ALJ hearings. Nonetheless there are some interesting pieces of information to be found in the manual. The chapter on contractor involvement in hearings reiterates that contractors who are not parties to the hearing may not object to the time of the hearing, call or cross-examine witnesses, or receive notices of decisions or dismissals.

One especially interesting fact revealed in the manual is that UPICs may not enter as parties to a hearing; they may only enter as non-party participants with more limited rights than parties to the hearing in question. For the other contractors, party status may not be elected before the receipt of a notice of hearing. This is important because, once a contractor elects to be a party to a hearing, the ALJ may not issue a decision on the record that is favorable to a provider—a hearing must be held. But in the event that an ALJ issues a favorable decision prior to sending a notice of hearing, no contractor may object.

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Finally, the case processing manual also clarifies that failure of an appellant to respond to the notice of hearing is not independent grounds for the dismissal of an appeal. The ALJ’s office is required to make attempts to contact the appellant first.

If the ALJ’s office is successful in reaching the appellant, a verbal acknowledgment of the notice of hearing may be given. This underscores the importance of periodically checking the ALJ Appeal Status Information System (AASIS) website maintained by OMHA to check the status of appeals and ensuring that accurate and up-to-date contact information is provided to any ALJ assigned to specific appeals.

Conclusion While it is certain that CMS plans to continue pursuing aggressive audits against inpatient rehabilitation hospitals and units—as well as other provider types—there are important safeguards in place to protect the rights of providers. It is important that providers be as informed as possible about the rules and requirements in place for MACs and other contractors. In being knowledgeable, providers will have the best chance of avoiding undue burdens during audits and protecting their rights throughout the appeal process.

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

Announcing The AMRPA QRP Certification Program A New Era for Rehabilitation has Begun!

Starting October 1, 2019, CMS is eliminating FIM from the IRF-PAI and introducing CMGs based on the GG-H QRP questions. AMRPA is working on key aspects of this change, from policy review and critique to helping hospitals adjust their day-to-day operations.

As part of this work, AMRPA is happy to announce the AMRPA QRP Certification Program.

Available in early 2019, this system will allow AMRPA member hospitals, as well as eRehabData® subscribers, to electronically test staff on their expertise of the QRP data elements in the IRF-PAI. The tests will be administered through AMRPA’s own eRehabData® system.

Best of all, AMRPA member hospitals and eRehabData® subscribers will have unlimited use of this powerful resource, free of charge.

Together, we can make the transition from FIM to GG-H smooth and seamless.

To learn more, please visit eRehabData.com

AMRPA Magazine / December 2018 11

The Middle of the IRF-PAI

Throughout this year that I have deemed “The Year of the PPS Coordinator,” my articles have focused on topics ranging from process, impairment group and comorbidity coding, and FIM™ scoring to quality indicator coding for functional items. This brings us to the remainder of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), which in my estimation includes the cognitive, continence, active diagnosis, falls and swallowing status sections.

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

The first cognitive items on the IRF-PAI relate to hearing, speech and vision. They ask if the patient is able to express ideas and wants, and understand verbal and nonverbal content. The answers are on a scale indicating “Rarely or Never Understanding or Expressing” to “Understands or Expresses Without Difficulty.” These should be completed on all patients at admission only.

The Brief Interview of Mental Status (BIMS) is a cognitive assessment that is used as a risk adjuster by the Centers for Medicare and Medicaid Services (CMS) as a means of comparing data among providers. The BIMS should be assessed upon admission, and it should be tested as close to the time of admission as possible. The IRF-PAI Training Manual does not indicate a specific discipline that can or should complete the assessment with a patient. CMS does indicate that the BIMS is required for patients who are able to participate in the assessment. Therefore, if you indicate that a patient is able to understand and express himself, then it would stand to reason that a BIMS score could be obtained.

For patients who are unable to participate in a BIMS assessment, the staff assessment is available to use instead. The BIMS asks the patient to restate three words immediately as well as after a delay with distractors, whereas the staff assessment asks the person completing the assessment if the patient would normally know the season, location of their room, staff names and faces, and where they are. People often confuse the staff assessment as a substitute for the BIMS in situations where BIMS was not assessed due to staff not conducting the assessment either in the first three days or prior to an unexpected discharge. However, the staff assessment is not a substitute for the BIMS in that sense.

I have advocated to include the BIMS as part of the nursing admission assessment to make sure that it is completed for all patients. Many providers have included the BIMS as part of the Occupational or Speech Therapy assessment. In cases where a patient is abruptly discharged to acute care, this may lead to an incomplete IRF-PAI due to lack of a BIMS. If you are completing the staff assessment as a substitute for the BIMS in cases where the BIMS was not tested and your patient is capable of completing

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the assessment, you are completing the IRF-PAI incorrectly.

An incomplete BIMS will result in an incomplete IRF-PAI that will count against your 5 percent threshold for incomplete assessments. If you exceed 5 percent of your IRF-PAI being submitted with incomplete data, you are subject to a 2 percent payment reduction for all Medicare claims.

The bladder and bowel continence items in section H of the IRF-PAI are straightforward. The documentation used to answer these questions should come from all pertinent documentation from the first three days of the patient’s stay. The IRF-PAI Training Manual indicates the definition of incontinence as referring “to the involuntary loss of urine, when there is a loss of control of the evacuation of urine from the bladder, regardless of whether clothing or linens are soiled.” Remember that there are responses for patients who do not urinate due to renal failure or chronic dialysis. Code this as “5 – No urine output.” Additionally, for patients who use indwelling bladder catheters, condom catheters, or ostomies, code “9 – Not applicable.” If the patient is continent, but voids on the floor related to a behavioral issue, do not code this as incontinence. Lastly, if a patient requires intermittent catheterization and is able to drain the bladder continently in between, code the bladder continence based on continence between catheterizations.

The bowel continence item pertains to the ability to voluntarily release stool in a commode or bedpan. Even if the patient requires assistance to stimulate a bowel movement, the item is coded based on whether or not the bowel movement resulted in a continent void. Coding “9 – Not rated” for patients who do not have a bowel movement in the first three days of the stay is advised.

Next, section I for active diagnoses include checking the presence of a comorbidity. Be cautious when marking these. When you code a condition in Item 22 or 24, make sure the information matches what is reported in section I. History of falls is an area where I often note discrepancies in the documentation. If the reason for admission to rehab is related to an injury from a fall, make sure the answer to item “J1750: History of Falls” is yes. I see the questions marked as “unknown” or “no”

when the patient had a fall with an injury immediately preceding the patient’s admission. You are also asked to report whether or not falls occurred and how many occurred during the stay. From the IRF-PAI Training Manual: “The definition of a fall is an unintentional change of position coming to rest on the ground, floor or onto the next lower surface. Falls are not a result of an overwhelming external force. An intercepted fall occurs when the patient would have fallen if he or she had not caught him/herself or had not been intercepted by another person-this is considered a fall.”

Whether or not the fall policy at your hospital or unit matches this definition, the number of falls recorded should match the definition as written in the IRF-PAI Training Manual. In addition to the number of falls, you will be asked to note if injuries were associated with the falls. If the patient sustains multiple injuries due to a single fall, the instructions indicate to code the fall for the highest level of injury. Injuries are divided into injury (except major) and major. Injuries except major include skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains.

Examples of major injuries include fractures, joint dislocations, closed head injury and subdural hematomas.

Section J asks about whether or not the patient had major surgery within 100 days prior to admission. Major surgery refers to a procedure requiring general anesthesia, carries some degree of risk to the patient’s life, the potential for disability if something goes wrong, and at least one overnight in an acute care hospital.

When answering the question in section J, make sure to consider if the patient had surgery immediately preceding the admission to the rehabilitation unit or hospital.

Finally, the swallowing and nutritional status of the patient is reported in section K. Remember to consider both diet and the need for supervision when you are answering these questions.

Multiple choices can be selected. If a patient is on a regular diet, but requires supervision for safety, you would mark both “A. Regular food” and “B. Modified food consistency/supervision.”

If a patient is receiving tube feeding and eating from a tray of modified consistency food, you would mark both tube feeding and modified food consistency/supervision.

Clarification In our November 2018 issue, in my article, Common Quality indicator Errors, I wrote, “Beginning in October 2020, we can expect the IRF-PAI to look even more different. “ This sentence should have read, “Beginning in October 2019, we can expect the IRF-PAI to look even more different.”

Our apologies for the error.

AMRPA Magazine / December 2018 13

MedPAC to Examine Post-Acute Care Functional Assessment Data

On November 1, the Medicare Payment Advisory Commission (MedPAC) held a public meeting session titled “Evaluating patient functional assessment data used in Medicare payment and quality measurement.” In the meeting, MedPAC staff sought the Commission’s guidance on a proposed analysis plan to evaluate the validity of post-acute care (PAC) functional status assessments, strategies to improve functional assessment, and potential alternative measures such as patient-reported outcomes data.

Mimi Zhang, Senior Policy and Research Analyst

Highlights: »»

MedPAC thinks there are shortcomings in how accurate post-acute care functional assessments are.

»»

MedPAC will address this topic in its June 2019 report to Congress.

Several dimensions of functional status are currently used into Medicare’s PAC payments and quality reporting programs to adjust payments, gauge provider performance and design care plans (see table below).

Setting

Dimensions of function used to establish payments

Dimensions of functional in quality reporting programs

IRF

Toileting, bathing, walking, dressing, transferring, grooming, eating, bladder and bowel control, cognition, communication

Self-care and mobility

HHA

Toileting, bathing, walking, dressing, transferring

Ambulation, bathing, bed transferring

SNF

Toileting, eating, transferring, bed mobility

Self-care and mobility

LTCH

None

Mobility of ventilator patients

Source: MedPAC

However, MedPAC has concerns about the accuracy of provider-reported data and whether they are accurately reflective of patient care needs. If the reported functional status does not match actual patient needs, program spending will be unnecessarily high, payments will not be aligned with resource needs, and outcomes may appear better than they are. Hence, the overarching questions driving the MedPAC’s analysis work are: Do the current provider-reported function data appear to be accurate?

What can CMS do to improve or help ensure the accuracy of this data?

Are there alternative measures of function that would be more accurate?

Should provider-reported function be used to establish payments and measure payment outcomes?

With regard to accuracy, the staff discussed what they believe to be discrepancies in functional status assessment data from inpatient rehabilitation facilities (IRFs) and home health agencies (HHAs). For IRFs, MedPAC has previously commented that high-margin

14 AMRPA Magazine / December 2018

IRFs appear to record lower patient function at admission than lowmargin IRFs. According to MedPAC, these findings suggest that assessment and scoring practices contribute to higher profitability of some IRFs. MedPAC also examined function and outcomes data in HHAs. Although HHA-reported data showed continued improvement in patients’ activities of daily living (ADLs) over time, there was not a corresponding improvement in claims-based outcomes (readmissions or emergency department use) over the same period, contrary to expectations for higher functioning patients.

Source: MedPAC

MedPAC staff expressed concerned that if provider-reported function data are used as a basis for payments, then providers’ coding of patient severity is likely to increase in a way that is unrepresentative of patient characteristics. MedPAC’s analytical plan for the coming months will include: Comparing assessments conducted for the same patient at discharge from one setting and at admission to the next PAC settings; Comparing the consistency of assessment items used for payment versus those used for quality reporting for the same patient (staff commented that they expect to see “broad agreement” in this comparison); and Comparing assessment information and other beneficiary characteristics such as age, risk scores, and frailty, among others.

Require acute care hospitals to complete a short discharge assessment for patients referred to PAC. CMS could then compare a patient’s functional status at discharge from the acute care hospital to the PAC provider’s admission assessment. One shortcoming of this method is that it would exclude community-admitted beneficiaries.

Collect function measures via patient-reported outcomes (PRO) tools. Staff suggested PRO indicators such as those used in Medicare Advantage Star Ratings program (namely the Improvement or maintenance of physical health from Health Outcomes Survey [HOS]), or in the Accountable Care Organization Consumer Assessment of Healthcare Providers and Systems (ACO CAHPS) survey. These approaches, however, are not without their own caveats: the Commission itself has concerns about the ability of the MA HOS tool to detect differences among plans, and the ACO CAHPS survey is a one-time response from a subset of the beneficiary population, and is therefore an unsatisfactory alternative to admission/discharge-based functional assessments. Furthermore, while PROs are viewed favorably by multiple health care stakeholders, there is limited research on their effectiveness as valid reporting items and particularly so in PAC settings.

Next Steps The Commission discussed at length about how best to evaluate functional assessment in PAC. Many Commissioners agreed that functional status is a key health care outcome that should be collected, and it is especially important for the patients treated in PAC. Commission Chairman Francis Crosson, MD, concluded the meeting with the observation that the Commission had not reached unanimous on any of the three alternative strategies presented.

While the Commission does not conclusively support any of the staff’s three posited alternatives, there is consensus that current functional assessment practices need to be improved for validity and objectivity. Chairman Crosson asked the staff to bring back ideas about how functional assessment can be used in measuring provider performance, if not for payment purposes.

MedPAC plans to include a chapter on this topic in the Commission’s June 2019 report to Congress.

The staff also suggested alternative strategies intended to enhance provider-reported assessments and sought the Commissioners’ feedback on these strategies: Improve monitoring of provider-reported assessments and penalizing misreporting. CMS could implement an audit program using Recovery Audit Contractors (RACs) or Quality Improvement Organizations (QICs) to conduct follow-up monitoring of providers with aberrant assessment patterns.

AMRPA Magazine / December 2018 15

AMRPA Submits Comments on Medicare Accountable Care Organizations Proposed Rule Editor’s Note: On October 16, AMRPA submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) in response to its proposed rule for Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). While AMRPA supported several of CMS proposals to innovate the Shared Savings Program, we expressed concern about the proposed acceleration for ACOs to bear downside risk and the potential negative impact this would have on Medicare beneficiaries’ access to post-acute care services. The complete letter is provided below.

October 16, 2018 The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244-1850 Delivered Electronically RE: CMS-1701-P “Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations—Pathways to Success” 83 Fed. Reg. 41786 (August 17, 2018) Dear Administrator Verma: This letter is submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) regarding the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) proposed rule, published in the Federal Register on August 17, 2018. AMRPA is the national trade association representing more than 625 freestanding inpatient rehabilitation hospitals and rehabilitation units of general hospitals (collectively referred to as inpatient rehabilitation facilities (IRFs) by Medicare), outpatient rehabilitation service providers, long-term care hospitals (LTCHs), and several skilled nursing facilities (SNFs).

Inpatient rehabilitation hospitals and units (IRH/Us) provide hospital-level care, which is significantly different in intensity, capacity, and outcomes from post-acute care (PAC) provided in non-hospital settings. AMRPA members help their patients maximize their health, functional ability, independence, and participation in society so they are able to return to home, work, or an active retirement. The vast majority of our members are Medicare participating providers and, on average, Medicare Part A payments represent more than 60 percent of IRH/U revenues.1 In 2016, IRH/Us served approximately 350,000 Medicare beneficiaries, representing more than 391,000 stays.2 We appreciate the opportunity to provide comments to the Centers for Medicare and Medicaid Services (CMS) regarding the MSSP ACOs, which constitute the most expansive of the agency’s value-driven alternative payment models (APMs). AMRPA has a demonstrated track record of supporting CMS in its pursuit of better alignment between incentives and high-value care delivery. We have continued to engage with the agency’s various initiatives for care and payment model innovations, providing comments on the Episode Payment Models (EPMs) and Comprehensive Care for Joint Replacement (CJR) rules, the Health Care Payment Learning and Action Network (HCP LAN) white papers, the CMS Innovation Center’s “New Directions” request for information, and most recently, the announcement of the Bundled Payments for Care Improvement Advanced (BPCI-Advanced) model.

While we commend CMS for considering innovative proposed changes to the MSSP beneficiary attribution policy and the beneficiary incentive program, we are concerned

1. Medicare Payment Advisory Commission, Report to Congress, Medicare Payment Policy, 267 (Mar. 2018).

2. Id.

16 AMRPA Magazine / December 2018

risk of incentivizing providers to limit costs and stint on care instead of prioritizing patient well-being, functional outcomes, and quality of life. The pursuit of value-based care, in which “value” is defined as outcomes divided by cost, can only be as robust as the outcomes and costs data available to make that assessment. Achieving and maintaining functional ability is a critically valuable outcome to patients and yet CMS has unfortunately declined to enhance or include robust functional outcome measures in the MSSP. AMRPA has previously urged the agency to enhance functional status quality measures for the ACO quality measure set, as well as those in numerous other programs.5 Functional status is also a clear driver of a patient’s resource utilization. Research has shown functional status to significantly outperform comorbidities as a predictor of a patient’s likelihood for readmissions following hospital discharge.6 Furthermore, the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) is predicated upon the causal relationship between a patient’s level of function and their resource use, and sets a precedent for CMS’ recognition of this relationship.

about the accelerated “glide path” for ACOs to bear downside risk and the potential negative impact this would have on the Medicare beneficiaries our members treat.

I. Unintended Consequences of Accelerating to Two-Sided Risk CMS proposes to fast-track the pathway for MSSP ACOs to assume financial risk by limiting the time in a one-sided risk model from the current six years to two years. CMS also proposes to reduce the shared savings rate in half for one-sided risk ACOs from 50 percent to 25 percent. Taken in combination, these proposals starkly intensify the financial risk—and instability— ACOs will experience. AMRPA is concerned that these financial pressures will cause ACOs to inappropriately focus on cutting costs over achieving high-quality outcomes, and consequently jeopardize beneficiaries’ access to PAC.

A. ACOs Limit Access to Post-Acute Care There is already evidence that the inherent conflict between the objectives of the MSSP (reduce unnecessary care and spending) and those of hospital-led ACOs (maintain admission volumes) has resulted in diminished access to medically necessary PAC. Earlier this year, the Medicare Payment Advisory Commission (MedPAC) remarked that MSSP ACOs generate savings not by reducing inpatient admissions, but through lowering utilization of other services such as outpatient facilities and professional services, imaging, tests, and PAC in particular. Notably, MedPAC concluded that it is attenuated PAC use—not fewer hospital admissions—that is the “primary source” of savings for MSSP ACOs.3 Both hospital-led and physician group-led ACOs, however, have dramatically limited their PAC utilization.4 ACOs are restricting the amount, duration, and scope of rehabilitation services: our members report that ACOs in their markets have adopted PAC management strategies that restrict access to certain settings secondary to cost considerations only. Furthermore, some ACOs have developed total PAC spending targets which limit admissions to certain PAC settings. Unfortunately, it is relatively easy for ACOs to reduce their overall spending by diverting patients away from PAC delivered in institutional settings such as rehabilitation hospitals and shift patients to lower-intensity PAC settings. Needless to say, such care management strategies – with spending targets that are administratively derived from retrospective claims data – are pronouncedly divorced from patient-centered decision-making that addresses the clinical needs of the patient at hand.

B. Value-Based Care Must Prioritize Functional Outcomes Any APM without adequate quality safeguards carries the

If CMS wants to ensure the most relevant health outcomes are tracked, it should require ACOs and all APMs to evaluate beneficiaries’ functional status, functional improvement, and the patient’s ability to sustain these improvements over longer periods of time. Medicare reforms should be built upon a solid evidentiary base that prioritizes patients’ wellbeing above all and certainly above pure cost-containment.

It would be short-sighted for CMS to enact policies that incentivize providers to focus more on generating savings in the short term rather than achieving high-quality patient outcomes in the long term, especially as better health outcomes lead to greater savings over the longer term.

AMRPA remains concerned that the pathway proposed in this rule would worsen the dynamics through which ACOs are delivering on costs savings, i.e., by reducing PAC services, and without adequate quality measures to counterbalance any stinting of care. We also find it concerning that, in seeking to fast-track the MSSP as proposed, CMS disregards external input suggesting that such changes are counter to the program’s viability.7

MRPA recommends that CMS not finalize its proposals A to accelerate the pathway for ACOs to bear greater financial risk. We urge CMS to instead focus on enhancing and evaluating the MSSP framework to ensure that the program is delivering on its objectives of improving or, at a minimum, maintaining the quality of beneficiary outcomes.

3. Medicare Payment Advisory Commission, “Medicare accountable care organization models: Recent performance and long-term issues.” Report to the Congress: Medicare and the Health Care Delivery System. June 2018. 230.

4. McWilliams J.M., Hatfield L.A., Landon B.E., Hamed P., and Chernew M.E., “Medicare Spending after 3 Years of the Medicare Shared Savings Program,” N Engl J Med 2018; 379:1139-1149. PAC use fell an average of -20 percent in hospital-led ACOs and -82 percent in physician-led ACOs compared with pre-MSSP baseline.

5. See AMRPA comment letters to the: Quality Payment Program for CY 2019 proposed rule [CMS-1693-P], Comprehensive Care for Joint Replacement proposed rule [CMS-5516-P], Episode Payment Models proposed rule [CMS-5519-P], and BPCI Advanced model announcement.

6. Shih, S., Gerrard, P. Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients. Journal of General Internal Medicine. (30)11, 1688-95. 2015 7. McWilliams J.M., Hatfield L.A., Landon B.E., Hamed P., and Chernew M.E., “Medicare Spending after 3 Years of the Medicare Shared Savings Program,” N Engl J Med 2018; 379:1139-1149. The authors found that one-sided MSSP ACOs could be more effective in lowering Medicare spending than previously estimated by CMS. They also recommend that policymakers not pursue more restrictive ACO policies as it may erode overall participation in the program and diminish potential savings to the Medicare Trust Fund.

AMRPA Magazine / December 2018 17

II. Enhancing Beneficiary Notification and Engagement

A. Beneficiary Notification Changes CMS proposes to modify the current MSSP beneficiary notification requirements to require a standard written notification that would be provided annually to each ACOattributed beneficiary at their first primary care visit of the performance year. AMRPA strongly supports this proposal. ACO providers should be required to disclose to beneficiaries that they are participating in an ACO and be transparent in explaining how this will impact their care. Our members report that, under the current notification processes, many patients who arrive at PAC are not aware that they are in an ACO or that their care options are affected by this fact. Hence a written notification would enable providers to inform beneficiaries about the ACO’s care model. It could also encourage a conversation about what “costs” and “quality” mean to the patient and help ACOs provide treatment that is tailored to the patient’s unique values and circumstances. CMS should foster any dialogue that orients care to being truly patient-centered.

For the MSSP to be successful for all parties, but especially for patients and their families/caregivers, patients must have full confidence that the decisions being made about their care are indeed in their best interests. While there is limited literature to date regarding the patient/caregiver perspective experience under ACOs, results from other capitated payment delivery models show that providers have significant room for improvement in this area. For instance, hospitals participating in the BPCI program have not been satisfactorily transparent or timely in their patient interactions. This includes not communicating to patients that their care will be provided under an alternative payment environment and the financial implications therein or not providing a thorough list of the post-discharge care options with meaningful information on the quality of care available.8,9 It is imperative for CMS to ensure that Medicare beneficiaries understand their freedom of choice when they are placed in a model in which one entity bears financial risk for the total cost of care across multiple provider settings.

To address these concerns, we recommend that: • CMS adopt its proposal requiring that MSSP ACOs notify beneficiaries of their inclusion in the ACO at their first primary care visit.

• CMS should also require ACOs to notify beneficiaries as early as possible, and along each step of the care continuum. This should include a notice to beneficiaries that they retain freedom of choice under Medicare FFS.

• CMS should require ACOs to provide beneficiaries with a list of all available PAC providers (IRH/Us, SNFs, LTCHs, and home health agencies) in their service area as part of the discharge planning process. The list should distinguish between those providers who are included or not included in any affiliated provider

network used by the ACO. Beneficiaries should also be informed as to the differences in the quality and intensity of care, capacity, and out-of-pocket costs among their various PAC options.

B. Changes to Beneficiary Attribution Methodologies CMS proposes changes to the beneficiary attribution processes to allow beneficiaries to designate or “elect” their attribution to an ACO. Specifically, CMS proposes to permit beneficiaries to voluntarily identify an ACO professional as their primary care provider, and CMS also proposes to create a beneficiary “opt-in” method. AMRPA supports adopting these revisions to the beneficiary attribution methodologies. Similar to our comments above, we are wholly supportive of policies that engage patients and give them greater agency in directing their care choices.

C. Creating a Beneficiary Incentive Program CMS proposes to allow ACOs in Track 2, Levels C, D, or E of the Basic Track, or the Enhanced Track to establish a beneficiary incentive program for eligible beneficiaries.

CMS proposes to limit the value of services/items furnished under the incentive program to $20 per qualifying service/ item. AMRPA supports permitting ACOs to establish a beneficiary incentive program, as an appropriately developed program will help patients adhere to a prescribed course of treatment. Transportation vouchers, for example, could greatly facilitate patients’ adherence to an outpatient therapy regimen. While ACOs should be able to notify beneficiaries of these incentives, AMRPA recommends that ACOs use template language supplied

by CMS regarding the availability of an incentive program. We additionally request that CMS clarify if the incentive payments are limited in any way per program year (e.g., a maximum of X incentive payments per beneficiary, or per physician).

III. Waivers

A. SNF Three-Day Stay Rule CMS proposes to expand eligibility for the SNF three-day rule waiver to include ACOs participating in a two-sided model under the preliminary prospective with retrospective reconciliation method of beneficiary assignment effective July 1, 2019. CMS also proposes to apply the three-day rule waiver to swing beds and eliminate the waiver’s “three-star or higher” requirement for these facilities.

AMRPA believes CMS’ criteria for waiving the SNF threeday rule overlooks the actual quality of care the beneficiary accessing a SNF may receive. Earning a three-star rating from CMS alone is insufficient evidence of a SNF’s readiness to treat patients on arrival from a three-day or less stay at an acute care hospital. CMS’ SNF Five-Star Quality Rating System is based on three criteria; one of the three levels— quality statistics—is self-reported by SNFs and accepted by

8. Joff, T. The Battle Of The Bundle: Lessons From My Mother’s Partial Hip Replacement. Health Affairs, 36(8), 1511-1514. August 2017.

9. The Lewin Group, CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4: Year 3 Evaluation & Monitoring Annual Report (Oct. 2017). 97-98. Lewin found that compared with non-BPCI patients, BPCI patients in some diagnosis groups were less likely to agree that: they were discharged at the right time, the medical staff clearly explained what follow-up care is needed prior to discharge, their care preferences for post-discharge services were considered, they understood how to take care of themselves after discharge, they received the appropriate level of care, and that patient preferences were accounted for in deciding post-discharge care.

18 AMRPA Magazine / December 2018

Medicare without verification, and another level—staffing levels—only stopped being self-reported for SNFs this past spring.10 An investigation of the SNF Five-Star Quality Rating System by The New York Times found only one of the criteria for which SNFs can earn stars, the results of annual health inspections, to be derived from assessments by independent reviewers.11 Generally, SNFs have been, and continue to be, the subject of HHS reports highlighting failure to meet minimum quality of care standards.12 For example, a 2014 report found as many as 22 percent of SNF residents experience adverse events during their stays; physician reviewers determined as many as 59 percent of these adverse and temporary harm events were preventable.13 Just last month, the Government Accountability Office (GAO) testified before Congress that between 2005 to 2014, there has been a 21 percent increase in the average number of consumer complaints per nursing home, and a 41 percent increase in the number of serious deficiencies—deficiencies that, at a minimum, caused harm to the resident.14 Additionally, SNFs generally have high acute care hospital readmission rates, and are only beginning to be held accountable for their patients’ hospital readmission rates through CMS’ implementation of 30-day hospital readmission payment penalties. Furthermore, SNFs, unlike hospital-levels of care, are not required to have an on-site pharmacy and may not have adequate medical staff capacity and infrastructure to properly serve the full range of patients.

AMRPA remains concerned about CMS’ proposal to expand the SNF three-day stay waiver in this rule. Most ACOs would be eligible for the waiver after two years under the MSSP, if not sooner, due to the accelerated pace to twosided risk. We urge CMS to comprehensively evaluate how the three-day rule waiver has impacted patient outcomes in the program to date before seeking to further expand waiver eligibility.

B. Telehealth CMS proposes to waive the telehealth “originating site of service” requirement and related geographic restrictions for certain telehealth services furnished by a physician or practitioner participating in an applicable ACO. AMRPA supports CMS’ adoption of these proposals and additionally recommends that CMS monitor the impact of telehealth services on patient outcomes.

IV. IRH/Us Need Alternative Reimbursement/Pricing and Regulatory Flexibility CMS has encouraged IRH/Us to participate in APMs such as ACOs. However, Medicare reimbursement for rehabilitation hospital services is very rigid, with a fixed per-patient discharge

prospective payment system based largely on factors outside of the IRH/U’s control, e.g., principal diagnosis in the preceding hospitalization. In contrast, other PAC providers have a greater degree of control over their Medicare costs, namely through reducing their “units” of utilization in either a per diem payment system (nursing homes) or a fixed-length episodic payment system (home health). Although IRH/Us are encouraged to collaborate with ACOs on delivering efficient Medicare spending, they are not given sufficient flexibility to adjust the costs associated with the resources used. To facilitate innovative care delivery, CMS should grant IRH/Us the flexibility to be responsive to market-based dynamics and not be constrained by an inelastic Medicare fee structure that effectively prices them out of APMs. I n promulgating the final rule, AMRPA urges CMS to make a number of modifications as described below. In addition to pricing flexibility, CMS clearly retains the regulatory authority to waive some or all of the restrictive requirements in the context of these models, and the agency has made similar concessions for other providers. Although CMS waived the significant and well-established SNF three-day stay rule, the agency has been unwilling to waive certain regulatory requirements that must be relaxed to facilitate IRH/U participation in the MSSP. Accordingly, various regulatory requirements should be waived in the context of specific APMs to allow IRH/Us to more effectively participate.

A. Alternative Reimbursement/Pricing Since ACOs are held responsible for PAC spending, this encourages IRH/Us, and other PAC providers, to produce high-quality outcomes at a reduced cost. Unlike some other PAC providers, however, rehabilitation hospitals are paid on a per-discharge basis for patients and Medicare rules do not allow IRH/Us to “charge less” in this context. ACOs therefore are incentivized to steer patients away from receiving hospital-level rehabilitation, even when it is imperative to patients’ recovery.

For IRH/Us to be able to remain a competitive and viable PAC setting within APMs, we recommend that CMS permit IRH/Us to receive reduced reimbursement, a per diem payment, or otherwise offer a discount from the IRF PPS amount if they so choose. Although this likely means that IRH/Us will be paid below cost for treating some patients in these programs, the alternative—that patients are denied access to inpatient rehabilitation altogether—is far worse for Medicare patients and the IRH/U providers who serve them. Since margins are very small or negative for the majority of IRH/Us,15 pricing flexibility must be voluntary, as should all alternative payment and care delivery concepts being tested.

10. See CMS’s webpage on the SNFs’ Five-Star Quality Rating System at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/ FSQRS.html.

11. Thomas, Katie, Medicare Star Ratings Allow Nursing Homes to Game the System, N.Y. TIMES, Aug. 24, 2014.

12. See the following Department of Health and Human Services Office of Inspector General Reports concerning nursing homes’ quality of care: CMS’s Reliance on California’s Licensing Surveys of Nursing Homes Could Not Ensure The Quality of Care Provided to Medicare and Medicaid Beneficiaries, A-09-12-02037, June 2014; Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring, OEI-06-11-00040, November 2013; and Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries, OEI-06-11-00370, February 2014.

13. Department of Health and Human Services Office of the Inspector General, Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries, OEI-06-11-00370, February 2014, at p. 2.

14. Government Accountability Office Testimony before the House Energy and Commerce Subcommittee on Oversight and Investigations, Nursing Home Quality: Continued Improvements Needed in CMS’ Data and Oversight, GAO-18-694T, September 6, 2018. 6.

AMRPA Magazine / December 2018 19

B. Regulatory Flexibility It is critical for IRH/Us to have sufficient regulatory flexibility to ensure they are able to deliver appropriate care in the APM context. AMRPA recommends that CMS relax the IRH/U intensity of therapy standard for those APM cases for which the provider has elected to receive reduced reimbursement. Specifically, the so-called Three-Hour rule (which CMS has traditionally interpreted to rigidly require three hours of intensive individualized therapy each day for five days per week that a patient is in an IRH/U) should not apply to cases for which the IRH/U has elected to receive reduced reimbursement under an APM framework.

I n addition, CMS should afford IRH/Us the option of including patients admitted under an APM as counting towards the IRH/U’s compliance with the 60 Percent Rule. Unlike other hospitals participating in Medicare, in order for IRH/Us to receive payment under their prospective payment system, they must have a patient mix that fits a very specific criterion. Known as the “60 Percent Rule,” the regulation mandates that 60 percent of all IRH/U patients (across all payers) must have diagnoses derived from 13 medical conditions. The list of 13 conditions is extremely outdated, having been expanded only once since its inception in 1975 (from 10 to 13 conditions), and limits IRH/ Us ability to evolve with the ever-changing medical treatment landscape. Innovations and advances in medicine over the past four decades have enabled patients with other serious diagnoses to not only survive acute care hospitalizations, but to also benefit tremendously from the intensive and multidisciplinary rehabilitation program provided in IRH/Us. However, these patients are often denied admission because they do not meet 60 Percent Rule compliance. We ask that CMS grant IRH/Us the option of counting patients admitted under ACOs towards their fulfillment of the 60 Percent Rule; this would afford IRH/Us the much-needed regulatory flexibility to more fully participate in alternative care and payment delivery models.

These approaches are consistent with CMS’ recent emphasis on expanding provider access to APMs, and has been favorably discussed by MedPAC in the context of reforming and advancing Medicare’s post-acute care payment systems.

CMS has the authority to permit such flexibility, and to waive these bureaucratic requirements without Congressional approval; the agency should do so both in the final rule and when promulgating any future models or changes to the current programs.

C. Administrative Presumption of Medicare Coverage under ACOs All patients admitted to IRH/Us from referring providers in an ACO, regardless of whether the IRH/U is receiving IRF PPS rates or reduced reimbursement, should be presumed to be covered in the rehabilitation hospital setting. Specifically, CMS’ contractors should not be permitted to deny payment for cases treated under ACOs based on prepayment review or post-payment reopening, unless there is evidence of fraud. ACOs are responsible for the cost and quality of care for their attributed beneficiaries are already held accountable for their PAC placement decisions by virtue of their financial and quality performance. Hence if a MSSP ACO chooses to discharge patients to an IRH/U, they should have full discretion to do so without Medicare contractor interference. CMS should instruct its contractors to respect an ACO’s PAC placement and utilization determinations.

AMRPA urges CMS to introduce more regulatory flexibility, such as allowing alternative pricing, relaxing siloed regulatory requirements, and presuming IRH/U coverage to allow for IRH/Us to fully participate in CMS efforts to create a more efficient Medicare system.

AMRPA members are committed to Medicare innovations that place patients back at the center of their care and achieve highquality and meaningful health outcomes. Thank you for your consideration of these comments as CMS continues to enhance the Shared Savings Program. If you have any questions, do not hesitate to contact Carolyn Zollar, JD, Executive Vice President for Policy Development and Government Relations (202-860-1002, czollar@amrpa.org) or Mimi Zhang, Senior Policy and Research Analyst (202-860-1003, mzhang@amrpa.org).

Sincerely,

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

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

15. For FY 2018, 43 percent of IRH/Us with available data had negative Medicare margins (below 0 percent) and 52 percent of IRH/Us had margins below 5.0 percent, based on AMRPA analysis of CMS Final Rule FY 2018 Inpatient Rehabilitation Facility Prospective Payment System rate setting files.

20 AMRPA Magazine / December 2018

AMRPA Submits Comments on Reforming Anti-Kickback Regulations Editor’s Note: On October 26, AMRPA submitted a response to the U.S. Department of Health and Human Services (HHS) Office of Inspector General’s (OIG) Request for Information (RFI) on modernizing the Anti-Kickback Statute regulations.

Provided below is an abbreviated version of the letter. The full response can be found on the AMRPA website.

Dear Mr. Levinson: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we appreciate the opportunity to respond to the Office of Inspector General’s (OIG) Request for Information (RFI) on the Anti-Kickback Statute and Beneficiary Inducements Civil Monetary Penalty published in the Federal Register on August 27, 2018.

Most inpatient rehabilitation hospital and unit (IRH/U) patients are referred from an acute-care hospital following a serious injury or illness, and at the IRH/U they will begin just one stage in their journey towards recovery. Due to the complex and serious nature of the conditions of patients treated in IRH/Us, they must be referred for a wide range of medical services following their departure from the IRH/U. In 2017, approximately 18 percent of IRH/U patients were discharged to SNFs, 45 percent were discharged to the care of home health organizations, and most of the remaining continued their rehabilitation on an outpatient basis. Therefore, due to the wide-range of services their patients require, IRH/Us are keenly aware of the need to properly monitor any referral relationships for inappropriate remuneration or inducements.

While providers like IRH/Us must continue to adhere to the complex and burdensome anti-kickback regulations, they are also facing increasing pressure from Medicare and other insurers to better coordinate care and ensure better long-term outcomes for patients. When the Anti-Kickback Statute was put in place, there was little to no accountability in Federal health programs for the effectiveness or efficiency of the care provided. Today’s environment stands in stark contrast, with almost all Medicare providers now held accountable for the value of the care provided through one Medicare mechanism or another. In addition to value-based accountability programs for providers, hospitals regularly undergo audits by Medicare or its contractors to determine the medical necessity of claims submitted.

Due to multiple checks on the quality, cost and medical necessity of care delivered to Medicare beneficiaries, it is no longer appropriate to maintain such expansive definitions of remunerations. In general, IRH/Us and other providers require much more flexibility to pursue legitimate value-based arrangements, both via models sponsored

by Medicare and arranged independently among Medicare providers, without risk of violating of anti-kickback or beneficiary inducement regulations. Coupled with our recommendation to provide more flexibility under anti-kickback regulations, AMRPA also recommends that OIG ensure there are sufficient patient safeguards in place to ensure that beneficiary access to needed care is protected.

I. OIG Should Create a Broad Safe Harbor Exclusion That Applies To All Legitimate Value-Based Arrangements.

OIG has issued numerous waivers for specific Medicare alternative payment models (APMs), and in doing so recognized that many value-based initiatives, such as shared savings programs, run afoul of anti-kickback or beneficiary inducement regulations.

However, these existing safe harbors are limited to specific APMs, and are also timelimited exclusions. This leaves no exclusion for providers attempting to engage in valuebased arrangements outside of these specific Medicare models.

As an example, IRH/Us currently report to the IRF Quality Reporting Program (IRF QRP), which tracks outcomes of patients after IRH/U discharge. However, it can often be challenging to ensure that a patient who is moving through the continuum of care and being treated by multiple providers continues to have all of their needs met. One strategy to tackle this difficult task is to engage a care coordinator who oversees the transitions and communication between providers. The care coordinator, usually a clinician, works to ensure all care needs are met for patients who may be moving from

AMRPA Magazine / December 2018 21

an acute-care hospital, to an IRH/U, and then to less intensive settings of care or home. This care coordinator ensures smooth transitions across settings and helps the patient to avoid any interruptions in care during the crucial recovery period. These care coordinators are an efficient way to break down of the silos of care that can exist in the current fee-for-service environment, and can be instrumental in ensuring positive long-term outcomes for patients.

The very nature of these care coordinators’ responsibilities means they are involved in referrals between and among multiple providers, triggering the need for compliance with anti-kickback regulations. Unfortunately, there is no broad exclusion from anti-kickback liability under current regulations for such an arrangement, despite its potential to enhance outcomes and improve efficiency. This leaves providers hesitant to engage in this type of venture for fear of potential liability. Additionally, because of variance in how differently situated hospitals and providers operate, advisory opinions issued by OIG can be only vaguely informative as to the legality of a specific provider’s desired arrangement. The net result is that providers are squeezed in both directions, with pressure to ensure the highest quality long-term outcomes, but also restricted from, or at least unsure of the legality of, directly engaging with other entities or providers in ways that can assist in achieving positive outcomes.

This is why the OIG should create a broad, bona fide value-based safe harbor for such activities. This bona fide value-based safe harbor should apply to all legitimate value-based arrangements, whether as part of an APM, a demonstration under Medicare, or arranged independently among Medicare providers. This safe harbor should be proposed and established through notice and comment rulemaking and propose definitions and permitted objectives for legitimate, value-based arrangements.

The permitted objectives for value-based arrangements covered by this safe harbor should include, but not be limited to, care coordination, interoperability of electronic medical records, transitions of care, and other safety or quality-enhancing objectives.

emphasis on cost reduction have advanced, patients with conditions like stroke are inappropriately diverted away from IRH/Us based on cost considerations alone. In fact, recent data from the Medicare Payment Advisory Commission (MedPAC) suggests that this may be the case for hospital-led accountable care organizations (ACOs). Specifically, MedPAC found that these organizations have generated savings not through reducing unnecessary hospital admissions, but largely by decreasing PAC utilization.

It is also clear that care stinting is not isolated to these newer Medicare demonstrations or APMs. Medicare Advantage (MA) plans, which operate on a capitated basis and thus bear risk for utilization, also show significant differences in access to IRH/U care. MedPAC has consistently found that MA enrollees are admitted to IRH/Us at approximately one-third the rate of Medicare fee-for-service beneficiaries. In addition, just last month your office raised serious concerns about access to needed services for MA beneficiaries in a report examining MA denial and appeal rates. This report cited the high overturn rate of MA denials and suspect accountability mechanisms for noncompliant MA organizations.

The evidence that current value-based payment arrangements may be leading to care stinting, as well as the potential for this care stinting to proliferate with more relaxed regulations, should be of great concern to OIG. As your office knows, any short-term savings to Medicare through underutilization of PAC services are ultimately offset by significant unnecessary long-term costs to Medicare or other federal and state programs. Disability, lack of function, hospital readmissions, and institutionalization create far greater expenditures in the long-term than any savings achieved through reduced payments for underutilization. Of course there are also the indirect costs of these negative outcomes on society, including in lost productivity, as well as unquantifiable costs in patients’ reduced quality of life, which can be dramatic when they are denied a chance to return to a full and fulfilling life through proper rehabilitation.

II. Value-Based Arrangements Carry Inherent Risk of Stinting on Patient Care and OIG Should Ensure Safeguards Are in Place to Protect Beneficiaries.

As discussed above, AMRPA encourages OIG to take steps to facilitate more innovative, value-based approaches to care delivery by creating a value-based safe harbor under the anti-kickback regulations. However, whenever a value-based arrangement places too much emphasis on cost reduction, without corresponding and robust accountability for patient outcomes, there is obvious risk that providers will be incentivized to stint on care. This is why, while supporting a regulatory change to more easily accommodate value-based arrangements, AMRPA also recommends OIG take further steps to ensure Medicare beneficiaries are not denied needed medical services due to these arrangements, given the susceptibility to stinting evident in other popular model designs.

To ensure Medicare beneficiaries are not denied access to the benefits that they are legally entitled, and to avoid unnecessary costs to Medicare and other federal programs, OIG should make certain the arrangements permitted under any safe harbor are truly quality enhancing ventures that have strong safeguards in place so patients can access medically necessary and appropriate care. The safeguards that should be in place include ample functional outcome measurement and quality accountability for any arrangements, since they are staples of any legitimate value-based arrangement. At a minimum, any permitted valuebased arrangement should require providers to be held more accountable for the quality of care and outcomes for patients, than the cost of care delivered. OIG should look skeptically upon any arrangements with too heavy an emphasis on cost control— driven by a quest to increase the amount of shared savings among participating providers—without equal weight placed on quality and outcomes.

AMRPA has found that the types of patients treated in an IRH/U are at particular risk for care-stinting due to their need for continuing, resource intensive treatments. More specifically, as value-based payment arrangements with a disproportionate

AMRPA also encourages OIG to assist in the development of additional consumer protections for any beneficiaries being treated under a value-based arrangement. Such protections should include continued freedom of choice so that Medicare

22 AMRPA Magazine / December 2018

beneficiaries are permitted to seek treatment outside of the value-based arrangement if they so desire, as well as a disclosure requirement that providers inform beneficiaries that they are being treated as part of a value-based arrangement. AMRPA also encourages OIG to thoroughly investigate the effect that value-based payment arrangements have on beneficiary access to health care. Specifically, your office should use its audit and investigation resources to examine utilization in APMs and other similar arrangements to help ensure there is not inappropriate care stinting.

AMRPA welcomes continued opportunities to collaborate with the Department of Health and Human Services and the Office of Inspector General to create value-based safe harbor regulations while ensuring access to necessary medical care and high-quality outcomes for all Medicare beneficiaries. If you have any questions about AMRPA’s recommendations, please contact me or AMRPA’s Regulatory and Government Relations Counsel, Jonathan Gold, J.D. (jgold@amrpa.org / 202-860-1004).

Sincerely,

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

Let’s Stay in Touch

AMRPA has new phone and fax numbers.

Please see the changes below to update your records.

AMRPA Government Relations & Policy Team AMRPA Main Phone: 202-591-2469 Fax: 202-591-2445

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

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

Lovelyn Robinson, AMRPA Researcher and Editor Direct Phone Line: 202-860-1005

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

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

AMRPA Magazine / December 2018 23

CY 2019 Home Health Rule Finalizes New Payment Model For 2020 On October 31, the Centers for Medicare and Medicaid Services (CMS) released the calendar year 2019 final rule with comment period for the Home Health Agency Prospective Payment System (HHA PPS). In this rule, CMS finalized its new Patient Driven Groupings Model (PDGM), which will be effective beginning calendar year 2020. The PDGM was mandated by Congress in the Balanced Budget Act of 2018, and requires CMS to implement the new model in a budget-neutral manner.

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

Highlights: »»

Payments for the new 30-day episode will be based on clinical subgroups, comorbidity and functional status, effective 2020.

»»

2019 payments to increase by 2.2 percent.

24 AMRPA Magazine / December 2018

As finalized, PDGM moves the HHA PPS from a 60-day episode of care to a 30-day episode of care payment system. The new 30-day payment model will eliminate the current wage-weighted minutes of care (WWMC) approach to determining resource use, and implement a new cost-per-minute plus non-routine supplies (CPM+NRS) methodology. This new CPM+NRS methodology will rely on cost reports submitted by HHAs to determine resource use and subsequent payment amounts for each Home Health Resource Group (HHRG).

The new HHRGs will be determined by the clinical grouping of the patient. CMS has finalized six clinical groups: Musculoskeletal Rehabilitation, Neuro/Stroke Rehabilitation, Wounds- Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care, Behavioral Health Care (including Substance Use Disorder), Complex Nursing Interventions, and Medication Management, Teaching, and Assessment (MMTA). The MMTA group will be further divided in to seven subgroups as follows: MMTA –Surgical Aftercare, MMTA – Cardiac/Circulatory, MMTA – Endocrine, MMTA – GI/GU, MMTA – Infectious Disease/Neoplasms/Blood-forming Diseases, MMTA –Respiratory, MMTA – Other. The table below from CMS breaks down the clinical groups and what CMS says is the most common primary reasons for home health treatment.

Clinical Groups

The Primary Reason for the Home Health Encounter is to Provide:

Musculoskeletal Rehabilitation

Therapy (physical, occupational or speech) for a musculoskeletal condition

Neuro/Stroke Rehabilitation

Therapy (physical, occupational or speech) for a neurological condition or stroke

Wounds – Post-Op Wound Aftercare and Skin/NonSurgical Wound Care

Assessment, treatment and evaluation of a surgical wound(s); assessment, treatment and evaluation of nonsurgical wounds, ulcers, burns, and other lesions

Behavioral Health Care

Assessment, treatment and evaluation of psychiatric conditions, including substance use disorder

Complex Nursing Interventions

Assessment, treatment and evaluation of complex medical and surgical conditions including IV, TPN, enteral nutrition, ventilator, and ostomies

Medication Management, Teaching and Assessment (MMTA) MMTA – Surgical Aftercare

Assessment, evaluation, teaching and medication management for surgical aftercare

MMTA – Cardiac/Circulatory

Assessment, evaluation, teaching and medication management for cardiac or other circulatory related conditions

MMTA – Endocrine

Assessment, evaluation, teaching and medication management for endocrine related conditions

MMTA – GI/GU

Assessment, evaluation, teaching and medication management for gastrointestinal or genitourinary related conditions

MMTA - Infectious Disease/ Neoplasms/Blood-forming Diseases

Assessment, evaluation, teaching and medication management for conditions related to infectious diseases, neoplasms, and bloodforming diseases

MMTA –Respiratory

Assessment, evaluation, teaching and medication management for respiratory related conditions

MMTA – Other

Assessment, evaluation, teaching and medication management for a variety of medical and surgical conditions not classified in one of the previously listed groups

The HHRGs will be further adjusted based on the functional status of the patient. The functional status will be determined by the provider evaluating the patient with the Outcome and Assessment Information Set (OASIS). Within each clinical subgroup there will be three levels of impairment (low impairment, medium impairment and high impairment), and HHRG payment rates are adjusted upwards for patients with higher impairment.

CMS has also finalized that HHRG will be adjusted by a patient’s comorbid status and CMS has put forward a list of comorbid conditions that qualify for adjustment. There will be three comorbidity statuses per HHRG: low comorbidity for patients with one comorbidity, high comorbidity for patients with two or more secondary qualifying diagnoses, and no commodity for patients with no qualifying diagnoses.

current system. In a sequence of episodes, only the first one will be classified as an early episode; all subsequent episodes will be considered late episodes, unless 60 days pass between the end of one episode and the beginning of a next.

The PDGM will also adjust payments by admission source.

Patients who were admitted a hospital or skilled nursing facility within 14 days prior to their HHA admission will be considered an institutional admission to HHA. All other admissions will be considered community admissions. In all, after all these potential adjustments are accounted for, the new methodology results in 432 unique HHRGs. When determining the HHRG payment rates and to ensure the PDGM is budget neutral, CMS is required to make assumptions about behavioral changes by HHAs, including coding and documentation changes that would occur as the result of this new model. CMS included several assumptions in its final calculation, which resulted in CMS reducing the base 30-day payment amount by approximately 6 percent from what it would have been absent these assumptions.

For 2019, prior to the move to the PDGM, CMS will be increasing payments to HHAs by 2.2 percent, which it estimates will result in a total increase of $420 million across the whole industry for the year. The 2.2 percent increase is the result of a 3 percent market basket update, which is decreased by a mandated 0.8 percent productivity adjustment.

CMS also made a number of other changes to the HHA PPS separate from its new payment model. Among those changes, CMS will now permit HHA to provide remote patient monitoring services and include that service as an operating cost on Medicare cost reports. CMS says this may eventually influence upward payment adjustments as these costs are considered in future payment updates. CMS also has removed the requirement that physicians must provide an estimate of how much longer skilled services will be required in recertifications for home health care.

There were also changes made to the Home Health Value-Based Purchasing (HHVBP) and the HHA Quality Reporting Program (QRP). For the HHVBP, CMS removed two OASIS measures, and replaced three other OASIS measures (Improvement in Bathing, Improvement in Bed Transferring, and Improvement in Ambulation-Locomotion) with composite measures on total change in self-care and mobility (Total Normalized Composite Change in Self-Care and Total Normalized Composite Change in Mobility). For the HHA QRP, CMS removed eight measures from the HHA Quality Reporting Program that it found redundant or no longer necessary.

Under the PDGM, CMS will also classify payment episodes as either “early” or “late” episodes, similar to what exists in the

AMRPA Magazine / December 2018 25

Robotic Arm May Help Rehabilitate Chronic Stroke Victims

Highlights: 

Robotic arm motor treatment may enhance rehabilitation for speech and language outcomes.

New research published in Frontiers in Neurology finds that robotic arm rehabilitation for chronic stroke patients with aphasia may promote speech and language function recovery. Robotic arm rehabilitation is a commonly used intervention for treating impaired motor function in the arm, wrist or shoulder subsequent to stroke.

The study targeted robotic rehabilitation of the right arm, as the participants had each suffered a left hemisphere stroke leading to a deficit in motor function on their right side. Individuals with left hemisphere strokes affecting motor function are also likely to have deficits in speech and language processing, and the study investigated whether those individuals may improve in their speech and language performance following treatment aimed at the domain of motor function. The research team observed small but consistent improvement on measures assessing speech articulation and overall language processing in aphasia. Overall, study subjects (n = 17) significantly improved on measures of motor speech production from pre-test to post-test. Of the subset who performed language testing (N = 9), overall aphasia severity on a standardized aphasia test improved from pre-test baseline to post-test.

According to the researchers, these findings show the importance of considering approaches to stroke rehabilitation across different domains of impairment, and warrants additional exploration of the possibility that robotic arm motor treatment may enhance rehabilitation for speech and language outcomes. They recommend further testing of these combined effects could enhance approaches to stroke rehabilitation for individuals with complex deficits affecting mobility, speech and language processing, and other cognitive domains.

The research was funded and supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health, under award number R01HD069776. New York University.

For the study, see Robotic Arm Rehabilitation in Chronic Stroke Patients With Aphasia May Promote Speech and Language Recovery (but Effect Is Not Enhanced

by Supplementary tDCS), Frontiers in Neurology, 22 October 2018.

26 AMRPA Magazine / December 2018

CMS Releases Nursing Home Compare Quality Reporting Program Data

Highlights: »»

CMS added five SNF QRP measures to Nursing Home Compare.

On October 24, 2018, the Centers for Medicare and Medicaid Services (CMS) announced the first release of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) quality data on Nursing Home Compare. The Social Security Act requires CMS to publicly display SNFs’ performance data on quality measures. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act also requires CMS to publicly report quality measure data submitted by SNFs on certain quality measures specified in the Act. Nursing Home Compare provides information on SNFs that are certified by Medicare and nursing facilities that are certified by Medicaid. The website contains data on the quality of resident care and staffing information for more than 15,000 nursing homes around the country, and will now include SNF QRP data that can be used to help compare facilities by their performance on quality indicators, such as the percentage of a SNF’s residents that develop pressure ulcers, or how many residents fall and are injured as a result of a fall.

The data on Nursing Home Compare demonstrates how a SNF’s performance on SNF QRP quality measures compares to that of other SNFs, as well as to the national average. The SNF QRP data used for calculating measures include claims data for some measures; for others the data are collected and submitted to CMS via the Minimum Data Set (MDS). SNFs must complete a MDS admission record and discharge record on each Medicare fee-for-service (FFS) resident. Several SNF QRP measures are calculated based on the admission and discharge data submitted for each SNF resident.

CMS has added the following five SNF QRP measures to Nursing Home Compare: Assessment-based measures: Percent of residents or patients in a SNF that develop new or worsened pressure ulcers (National Quality Forum #0678) Percentage of residents or patients whose activities of daily living and thinking skills were assessed and related goals were included in their treatment plan (NQF #2631) Percentage of SNF patients who experience one or more falls with major injury during their SNF stay (NQF #0674) Claims-based measures: Medicare Spending Per Beneficiary (MSPB) for residents in SNFs

AMRPA Magazine / December 2018 27

Rate of successful return to home or community from an SNF CMS did not publish the sixth quality measure, Potentially Preventable 30-Day Post-Discharge Readmissions, to allow for more testing to determine if there are modifications that may be needed both to the measure and to the method for displaying the measure. CMS says the additional testing will ensure that future publicly reported measure is thoroughly evaluated so that Compare users can depend upon an accurate picture of provider quality. CMS will not post

reportable data for this measure while it is conducting further testing.

The following table lists the new SNF QRP measures that are included on Nursing Home Compare and the national average rate of performance on the measures.

See the Skilled Nursing Facility Quality Reporting Program page on the CMS website for more information.

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Measure Name and Description

National Rate of Quality Measure Performance

Minimum Data Set (MDS)-based Measures Percent of Residents or Patients in a SNF that develop new or worsened pressure ulcers (National Quality Forum #0678)

1.7%

• Percent of patients that developed new or worsening pressure ulcers during their stay in an SNF Percentage of residents or patients whose activities of daily living and thinking skills were assessed and related goals were included in their treatment plan (NQF #2631)

95.8%

• Percentage of patients whose activities of daily living and thinking skills were assessed and related goals were included in their treatment plan Percentage of SNF patients who experience one or more falls with major injury during their SNF stay (NQF #0674)

0.9%

• Percentage of patients that experienced a fall that resulted in a major injury during their stay in a SNF SNF Claims-based Measures Medicare Spending Per Beneficiary (MSPB) for patients in SNFs

1.01

• Shows whether Medicare spends more, less, or about the same on an episode of care for a Medicare patient treated in a specific SNF compared to how much Medicare spends on an episode of care across all SNFs nationally Rate of successful return to home or community from an SNF • T he rate at which patients returned to home or community from the SNF and remained alive without any unplanned hospitalizations in the 31 days following discharge from the SNF.

28 AMRPA Magazine / December 2018

48.57%

Physician Practices Joining Early ACOs Were Large and Capable, but Performance Was Modest

Highlight: »»

Physician practices that intended to join Medicare ACO programs in 2012 had greater capabilities to manage risk and succeed under a value-based payment model than practices that did not.

// The researchers examined physician practices to assess whether the characteristics and capabilities of individual practices intending to join the early Medicare ACO programs differed from those of practices not intending to join.

By 2020, an estimated 68 million people will be enrolled in an accountable care organization (ACO), according to some projections. And while ACOs seek to address rising health care costs and inconsistent quality of care, evidence of savings achieved is limited, and ACOs’ performance has varied widely, according to a study published in the American Journal of Managed Care and funded by the Commonwealth Fund.

The researchers examined physician practices to assess whether the characteristics and capabilities of individual practices intending to join the early Medicare ACO programs differed from those of practices not intending to join. Specifically, the study examined differences with regard to patient sociodemographic characteristics and disease burden, practice characteristics and capabilities, and cost and quality measures. Data sources include a 20122013 national survey of 1,398 physician practices linked to 2012 Medicare beneficiary claims data.

Study Findings Physician practices that intended to join a Medicare ACO program were more likely to have better care management capabilities, quality improvement processes, and health information technology functionality than those that did not. ACO practices were more likely to have had experience with pay-for-performance models. They also tended to be hospital-owned, have a greater number of Medicare beneficiaries, and have more than 100 physicians. There were no differences between practices intending to participate in an ACO and those not intending to participate with regard to patient demographic characteristics, illness severity, baseline Medicare spending per beneficiary, ambulatory care–sensitive admission rates, or 30-day unplanned hospital readmissions. The study

AMRPA Magazine / December 2018 29

also found that top-performing physician groups used only 45 percent–50 percent of recommended care management, quality improvement, and health IT processes.

Physician practices opting to join Medicare ACO programs in 2012 tended to be larger and more confident in their ability to manage their patients’ care effectively, contain costs and improve quality.

Even these early adopters, however, often failed to implement key capabilities, using no more than half of recommended processes for care management, health information technology, and quality

improvement. Although physician practices that intended to join Medicare ACO programs in 2012 had greater capabilities to manage risk and succeed under a value-based payment model than practices that did not, the performance of these ACOs has been modest.

For the study see, The Characteristics of Physician Practices Joining the Early ACOs: Looking Back to Look Forward, American Journal of Managed Care 24, no. 10 (Oct. 2018): 294–99.

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

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

30 AMRPA Magazine / December 2018

Disparities in Readmission Rates Between Patients Discharged from Safety-Net or Non-Safety-Net Hospitals

Highlights: »»

Disparities are widening within safety-net hospitals, specifically for non–HRRP-targeted conditions.

// The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012.

Under this program, hospitals are Disparities between white and black financially penalized patients might widen because more black patients receive care at safety-net if they have higher hospitals. Disparities may be particularly worse for clinical conditions not than expected risktargeted by the HRRP because hospitals might reallocate resources toward standardized targeted conditions (acute myocardial infarction, pneumonia, and heart 30-day readmission failure) at the expense of nontargeted conditions. rates for acute The Affordable Care Act (ACA) myocardial infarction, established the Hospital Readmission Reduction Program (HRRP) in 2012. heart failure and Under this program, hospitals are financially penalized if they have higher pneumonia.

Although readmission rates are declining under Medicare’s Hospital Readmissions Reduction Program (HRRP), concerns remain that the HRRP will harm quality at safety-net hospitals because they are penalized more often.

A recent study published in JAMA Network Open examined disparities in readmission rates between white and black patients discharged from safetynet or non–safety-net hospitals after the HRRP began, evaluating discharges for any clinical condition and the subsets of targeted and nontargeted conditions.

than expected risk-standardized 30-day readmission rates for acute myocardial infarction, heart failure and pneumonia.

Since the announcement of this policy,

AMRPA Magazine / December 2018 31

readmission rates in the United States have declined for HRRPtargeted conditions and, to a lesser degree, for nontargeted conditions. Despite the perceived success of the HRRP, concerns remain that safety-net hospitals could be harmed by HRRP penalties.

Study Design The study cohort included Medicare fee-for-service beneficiaries discharged from acute-care hospitals from January 1, 2007, through September 30, 2015, with any clinical condition.

Inclusion criteria were patients 65 years or older who survived their hospitalization and were identified in the data set as either black or white (95 percent of all discharges). The study applied the HRRP exclusion criteria and excluded Medicare beneficiaries who were not enrolled in fee-for-service Medicare for one year prior to hospitalization and the month after hospital discharge, were discharged against medical advice or to hospice, and for whom the primary reason for hospitalization was a psychiatric condition, rehabilitation, or medical cancer treatment. The study sample included 58 237 056 patient discharges (black patients, 9.8 percent; female, 57.7 percent; mean age [SD] age, 78.8 [7.9] years; nontargeted conditions, 50 372 806 [86.5 percent]).

Results The main outcomes and measures were trends in 30-day readmission rates among white and black patients by quarter and differences in trends across periods. Black patients had

32 AMRPA Magazine / December 2018

worsening readmission rates in safety-net hospitals, specifically among clinical conditions not targeted by the HRRP, whereas differences among targeted conditions were stable. Within non–safety-net hospitals, racial disparities did not change for patients discharged with targeted or nontargeted conditions.

Within safety-net hospitals, disparities in readmission rates for all clinical conditions widened between black and white patients by 0.04 percentage point per quarter in the HRRP penalty period (95 percent CI, 0.01 to 0.07; P = .01). This widening was driven by nontargeted conditions (0.05 percentage point per quarter [95 percent CI, 0.01 to 0.08]; P = .006), whereas disparities for the HRRP-targeted conditions did not change (with an increase of 0.01 percentage point per quarter [95 percent CI, −0.07 to 0.10]; P = .74).

The study findings suggest that disparities are widening within safety-net hospitals, specifically for non–HRRP-targeted conditions. Although increases in racial disparities for nontargeted conditions were modest, they represented six times more discharges in the cohort than targeted conditions.

For the study, see Changes to Racial Disparities in Readmission Rates After Medicare’s Hospital Readmissions Reduction Program Within Safety-Net and Non–Safety-Net Hospitals, JAMA Network Open. 2018, November 2, 2018.

New Therapy Technique Doubles Movement Recovery in Stroke Patients

Highlight: »»

Targeted plasticity therapy along with traditional motor-skill rehabilitation was found to be twice as effective as traditional rehabilitation alone.

Researchers at the University of Texas at Dallas have developed a therapy technique that has been shown to double the rate of upper limb recovery in stroke patients.

The results of the study published in the journal Stroke indicate that targeted plasticity therapy (TPT) — which involves stimulation of the vagus nerve — paired with traditional motor-skill rehabilitation is safe and can be twice as effective as traditional rehabilitation alone.

Nearly 800,000 Americans suffer strokes each year and limb mobility can be affected when nerve cells are damaged. Such forms of brain trauma are often treated with rehabilitation that includes repeated movement of the affected limb in an effort to regain motor skills. The approach is thought to work by helping the brain reorganize.

// Nearly 800,000 Americans suffer strokes each year and limb mobility can be affected when nerve cells are damaged. Such forms of brain trauma are often treated with rehabilitation that includes repeated movement of the affected limb in an effort to regain motor skills.

Researchers affiliated with the Texas Biomedical Device Center (TxBDC) and the University of Texas at Dallas developed the therapy technique, which pairs physical movements with precisely timed vagus nerve stimulation (VNS) — electrical stimulus of the nerve via a device implanted on the nerve in the neck. The vagus nerve controls the parasympathetic nervous system, overseeing many unconscious functions such as circulation and digestion. Stimulating the nerve initiates neural plasticity — reorganization of the brain’s circuitry. The idea behind TPT is that synchronizing VNS with movement accelerates plasticity in a damaged brain, and with it, recovery.

The study involved 17 stroke patients whose stroke occurred between four months and five years prior to selection. After they had a VNS device implanted, the subjects received six weeks of in-clinic rehab followed by a home exercise program. About half were treated with active VNS while the rest received control VNS. All were assessed one,

AMRPA Magazine / December 2018 33

30 and 90 days after therapy with a widely used, stroke-specific measure of performance impairment.

In addition to showing that the technique is safe, the researchers found that subjects receiving active VNS scored more than twice as high as control subjects at the 30- and 90-day intervals, thus opening the way for larger, more extensive clinical trials.

The researchers said that the study results further validate the theories they have worked on since 2009. “We set out to design an approach that could transform long-term care and restore quality of life to patients for whom that has thus far been impossible,” said Dr. Michael Kilgard, who invented TPT and

is associate director and chief science officer of the TxBDC. “These results show our method has immense potential. We’re excited about what this could mean for millions of stroke patients worldwide.”

Other institutions involved in the study included the University of Texas Health Science Center at Houston; the University of Minnesota; the University of California, Irvine; the University of Glasgow; and Massachusetts General Hospital.

For the study, see Enhanced Rehab for Stroke Doubles Movement Recovery, University of Texas at Dallas.

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EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE

AMRPA: Working Together to Preserve Preserve Access to Medical Rehabilitation AMRPA: Working Together To Access To Medical Rehabilitation Maggie Ramirez · VP ofMember Membership Services · 347-573-3732 · mramirez@amrpa.org Julia Scott, AMRPA Services Coordinator, 202-207-1110, jscott@amrpa.org

34 AMRPA Magazine / December 2018

Study Examines the Association Between Patient Outcomes and Accreditation

Highlights: »»

Patients treated at accredited hospitals had slightly lower 30 day mortality rates.

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Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals.

A recent study published by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network examined whether patients admitted to accredited hospitals have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by the Joint Commission was correlated with different patient outcomes compared with other independent accrediting organizations.

Of the 4,400 hospitals examined, 3,337 were accredited (2,847 by the Joint Commission) and 1,063 underwent state-based review between 2014 and 2017. The study participants included 4,242,684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS).

// Of the 4,400 hospitals examined, 3,337 were accredited (2,847 by the Joint Commission) and 1,063 underwent state-based review between 2014 and 2017.

The main outcome measures were risk-adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission.

The study found that patients treated at accredited hospitals had lower 30-day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2 percent v. 10.6 percent, difference 0.4 percent (95 percent confidence interval 0.1 percent to 0.8 percent), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4 percent v. 2.4 percent, 0.0 percent (−0.3 percent to 0.3 percent), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4 percent v. 23.2 percent, 0.8 percent (0.4 percent to 1.3 percent), P<0.001) but did not differ for the surgical conditions (15.9 percent v. 15.6 percent, 0.3 percent (−1.2 percent to 1.6 percent), P=0.75). No statistically significant differences were seen in 30-day mortality or readmission rates (for both the medical or surgical conditions) between hospitals

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accredited by the Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 v. 3.2, 0.2 (0.1 to 0.3), P<0.001).

Among accredited hospitals, the Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 v 3.2, 0.1 (â&#x2C6;&#x2019;0.003 to 0.2), P=0.06).

The study concluded that U.S. hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates

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for the 15 common medical conditions selected in the study.

The study also did not find differences in outcomes for patients treated at hospitals accredited by the Joint Commission versus those treated at hospitals accredited by another independent accrediting organizations.

For the study, see Association between patient outcomes and accreditation in U.S. hospitals: observational study, AHRQâ&#x20AC;&#x2122;s Patient Safety Network, October 18, 2018.

Latest Research Findings

Survey Assess Changes in the Prevalence of Health Care-Associated Infections Four percent of hospitalized patients had a health care-associated infection (HAI) according survey conducted in the United States in 2011. The survey was repeated in 2015 to assess changes in the prevalence of health care-associated infections during a period of national attention to the prevention of such infections, and these findings were recently published in the New England Journal of Medicine.

At Emerging Infections Program (EIP) sites in 10 states, up to 25 hospitals were recruited in each site area, prioritizing hospitals that had participated in the 2011 survey. Each hospital selected one day on which a random sample of patients was identified for assessment. Trained staff reviewed medical records using the 2011 definitions of HAIs, compared the percentages of patients with HAIs and performed multivariable log-binomial regression modeling to evaluate the association of survey year with the risk of HAIs.

The study found that the prevalence of health care-associated infections was lower in 2015 than in 2011 and the researchers state that in order to continue to make progress in the prevention of such infections, prevention strategies against C. difficile infection and pneumonia should be augmented. The study was funded by the Centers for Disease Control and Prevention (CDC).

For the study, see Changes in Prevalence of Health CareAssociated Infections in U.S. Hospitals, New England Journal of Medicine, 2018 Nov 1;379(18):1732-1744.

In 2015, a total of 12,299 patients in 199 hospitals were surveyed, as compared with 11,282 patients in 183 hospitals in 2011. Fewer patients had HAIs in 2015 (394 patients [3.2 percent; 95 percent confidence interval {CI}, 2.9 to 3.5]) than in 2011 (452 [4.0 percent; 95 percent CI, 3.7 to 4.4]) (P<0.001), largely owing to reductions in the prevalence of surgical-site and urinary tract infections.

Pneumonia, gastrointestinal infections (most of which were due to Clostridium difficile), and surgical-site infections were the most common HAIs. Patients' risk of having an HAI was 16 percent lower in 2015 than in 2011 (risk ratio, 0.84; 95 percent CI, 0.74 to 0.95; P=0.005), after adjustment for age, presence of devices, days from admission to survey, and status of being in a large hospital.

AMRPA Magazine / December 2018 37

Patient Satisfaction and Perceived Quality of Care Among Younger Medicare Beneficiaries A recent study published in the Archives Physical Medicine and Rehabilitation examined the association between activity limitation stages and patient satisfaction and perceived quality of medical care among younger Medicare beneficiaries.

The study participants included a population-based sample of 9,323 Medicare beneficiaries less than 65 years of age living in the community. The main outcome measures were categorized under five patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physician (PCP), interpersonal skills of PCP, and quality of information provided by PCP. People were classified into an activity limitation stage (0-IV) which was derived from selfreported difficulty performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

The study found that compared to beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (OR) (95 percent confidence intervals (CI)) for stage I (mild) to stage IV (complete) for satisfaction with access barriers ranged from 0.62 (0.53-0.72) at stage I to a minimum of 0.31 (0.22-0.43) at stage IV. Similarly, compared to beneficiaries at IADL stage 0, satisfaction with access barriers ranged from 0.66 (0.55-0.79) at stage I to a minimum of 0.36 (0.26-0.51) at stage IV. Satisfaction with care coordination and quality and perceived quality of medical care were not associated with activity limitation stages.

Younger Medicare beneficiaries with disabilities reported decreased satisfaction with access to medical care, highlighting the need to improve access to healthcare and human services and to enhance workforce capacity to meet the needs of this patient population.

For the complete study, see Patient Satisfaction and Perceived Quality of Care among Younger Medicare Beneficiaries According to Activity Limitation Stages, Archives Physical Medicine and Rehabilitation, 2018 Oct 11.

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