AMRPA Magazine October 2018 by AMRPA

October 2018 â&#x20AC;¢ Vol. 21, No.10

Charting a New Course

October 2018 • Vol. 21, No. 10

The official publication of the American Medical Rehabilitation Providers Association (AMRPA) Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation

Table of Contents Letter from the Chair

Legislative Update

AMRPA Strongly Opposes Proposed RAC Issue—IRF Stays: Medical Necessity

A Review of the Sections B, C, GG and H IRF-PAI Quality Indicators

John Ferraro, MS AMRPA Executive Manager

Medicare Payments Continue to Expand Payments Over Costs by State

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

IRF PAI and Quality Reporting Changes Starting October 2018

AMRPA Submits Comments to CMS on Modernizing Stark Self-Referral Regulations

AMRPA Submits Recommendations to CMS Regarding CY 2019 Physician Fee Schedule, Quality Payment Program, and Medicare Shared Savings Program Proposed Rule

NIDILRR Issues 2017 Disability Statistics Annual Report

Visual Training and Rehabilitation in Restoring Partial Blindness

Analyzing Quality of Life and Function in Traumatic Spinal Cord Injury Patients

Study Assesses the Association of Medicaid Expansion, Access to Rehabilitation and Unplanned Readmissions among Hospitalized Young Adult Trauma Patients

Presence of Pressure Ulcers Associated with Poorer Functional Outcomes in Inpatient Rehabilitation Patients

Study Finds Differences in Outcomes for BPCI Model 2 Cardiac Bundles Participants and Non-Participants

Hospital Participation in the BPCI Was Not Associated with Significant Changes in Volume or Most Patient Case- Mix Factors

Latest Research Findings

Federal Elections Center

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

AMRPA Magazine, Volume 21, Number 10 AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA). AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Individuals who are employees of member institutions may subscribe to the magazine for $100 annually. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color. Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Samantha Schwarz, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1132, Email: sschwarz@amrpa.org Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content ©2018 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Kellen Company. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 750, Washington, DC 20045

AMRPA Magazine / October 2018

Letter from the Chair

Charting a New Course It seems clear to me that we need leaders to embrace change and transform their own institutions to meet ongoing demands. Many of these demands are imposed upon us from outside sources. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) is an example of such an external demand. It will take strong leadership to successfully navigate these internal and external challenges.

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

The IMPACT Act was enacted to reform the Medicare post-acute care payment system by collecting standardized data on the following: patient assessment elements, outcomes and resources. AMRPA has long recognized the need to transition toward a unified post-acute payment system and supported the timeline originally required under the IMPACT Act. CMS’s Fiscal Year 2019 IRF PPS Final Rule changed the timeline established in the IMPACT Act. Also, CMS has not yet introduced standardized patient assessment elements to all post-acute care providers. AMRPA remains committed to the IMPACT Act despite the challenges that we face. As leaders we need to be prepared to accept change. The title of a recent commentary in Modern Health Care caught my attention which read, “Transformed leaders needed if we hope to succeed in transforming health care (as cited in Sorenson 2018).” In some respects health care is changing regardless of the power or skill set of the leader. What we need to transform health care proactively are leaders on two fronts, those who can adapt their organizations to a changing health care landscape and those who can find opportunities and be innovative within a highly regulated field. To this point, Bass and Avolio (1993) years ago wrote that effective organizations are shaped by its leaders creating and building organizational cultures. The leader must guide the development of a vision. The leader can then develop an organization that is dedicated to seeing the vision realized. The authors go on to say that transformational leaders are able to align their employees around the vision thus moving to its realization. It is incumbent upon us as rehabilitation leaders to understand the challenges and potential changes faced by our industry. The changes imposed upon us by external forces, such as the IMPACT Act, provide us with an opportunity, sooner or later, to ensure that we set a vision for our organizations that accepts and adapts to change.

REFERENCES Sorenson, C.W. (2018, Sept 1) Transformed leaders needed if we hope to succeed in transforming health care. Retrieved from http://www.modernhealth care.com/article/20180901/NEWS/180829906 Bass, B.M. & Avolio, B.J. (1993). Transformational leadership and organizational culture. Public Administration Quarterly, 17(1), 112-121.

AMRPA Magazine / October 2018

FAIR FUND Fund for Access to Inpatient Rehabilitation

HAVE A HAND IN THE SOLUTION

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

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

Legislative Update

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

Highlights: »»

Congress returned after Labor Day and immediately turned its attention to finalizing Fiscal Year (FY) 2019 spending before federal funding ran out on September 30, 2018; focused on reauthorizing multiple major government programs; and efforts directed toward confirming a Supreme Court justice nominee.

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In September, the Senate sought to pass an opioid package, which will likely set up conference negotiations with the House later this fall.

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As part of the next step in its Medicare Red Tape Relief Project, the House Ways and Means Committee sent three letters to Centers for Medicare and Medicaid Services (CMS) Administrator Verma with a variety of recommendations that reduce legislative and regulatory burdens in the Medicare program.

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MedPAC continues to analyze a unified payment system for post-acute care.

Congressional Activity on Appropriations Heats Up as Funding Deadline Looms On August 23, the Senate voted 85-7 to pass H.R. 6157, as amended, a two-bill minibus that contains the fiscal year (FY) 2019 Defense and Labor-HHS-Education appropriations measures. The $179.3 billion Labor-HHS bill funds the Department of Health and Human Services (HHS) at $90.1 billion and includes a $2 billion increase for the National Institutes of Health (NIH). The bill also contains a $3.5 billion funding boost for opioid response. Several notable amendments were added to the final package, including two opioid-related proposals and an amendment to implement rules that would require drug makers to disclose list prices in direct-to-consumer advertising. Work to reconcile the Senate and House versions of the Labor-HHS measure began immediately after Labor Day, though it is likely that Labor-HHS and the contentious Homeland Security appropriations measure will be wrapped up in a Continuing Resolution (CR) package at the end of September. Although there has been unprecedented bipartisanship over considering Appropriation bills via regular order, the limited days Congress is in session due to the midterm elections may cause Congress to rely on a CR for a number of the appropriations measures and force much of the fall agenda into a post-election, Lame-duck session or even into 2019. Beyond appropriations, the Senate has quite a few other items that it may attempt to address this fall. As we go to print, the Senate just completed negotiations on a Chairman’s mark of the opioid package that Senate leaders anticipate debating and passing this month. It will then set up bicameral conference negotiations with the House. Senators could also take action on the Water Resources Development Act reauthorization and/or possibly the Farm Bill. In addition to the busy legislative agenda, the Senate will also continue to consider executive and judicial nominations. Chief among these will be the marquee judicial confirmation battle over Judge Brett Kavanaugh to serve as an Associate Justice on the Supreme Court. Nominated by President Trump on July 9, Judge Kavanaugh currently serves on the D.C. Circuit of Appeals. Judge Kavanaugh’s confirmation hearing began on September 4 and despite a somewhat contentious opening day, his nomination appeared to be on an unobstructed political path forward. However allegations of sexual assault that took place several decades ago may derail his confirmation process. As we go to print, the Judiciary Committee is planning to hold a hearing on the accusations on Monday, September 24, but it is not clear whether Judge Kavanaugh’s accuser will testify under oath. Judge Kavanaugh has denied the allegations and will testify under oath. Drug Pricing Remains a Priority for Congress and Trump Administration On August 22, HHS released a brief report outlining actions the agency has taken in the 100 days since the administration released the American Patients First blueprint on drug

AMRPA Magazine / October 2018

pricing. The report states that much of the blueprint is “still in the works,” and that some proposals will require legislative action. CMS took several administrative actions in August to address drug pricing, announcing August 7 that it will permit Medicare Advantage (MA) plans the option of applying step therapy for physician-administered and other Part B drugs beginning January 1, 2019. Additionally, on August 29, CMS issued guidance to allow Medicare Part D plan sponsors to use indication-based formulary design beginning in 2020. According to CMS, this change will help strengthen plans’ negotiating leverage with manufacturers. On September 5, the Senate passed by unanimous consent the bipartisan Know the Lowest Price Act (S. 2553) that prohibits “gag clauses” between pharmacists and pharmacy benefits managers (PBMs). The bill will allow pharmacists to alert their customers that paying out-of-pocket may be cheaper than using their prescription drug insurance benefit, making it easier for Medicare beneficiaries to pay the lowest price on their drugs. Looking ahead, the Office of Management and Budget (OMB) is now reviewing an HHS Office of Inspector General proposed rule that would both eliminate and create new safe harbor protections related to drug rebates for pharmacy benefit managers. FDA Commissioner Scott Gottlieb and HHS Secretary Alex Azar have both discussed the possibility of re-examining the safe harbors for drug rebates. OMB is also reviewing a proposed rule on drug pricing transparency; it is expected this will propose requiring the disclosure of price information in direct-to-consumer advertising by pharmaceutical manufacturers. Medicare Red Tape Relief Project Recommendations Sent to CMS On August 15, House Ways and Means Committee Chair Kevin Brady (R-Texas) and Health Subcommittee Chair Peter Roskam (R-IL) released an eight-page report on the committee’s Medicare Red Tape Relief project, outlining ideas to reduce legislative and regulatory burdens in the Medicare program. The report summarizes the stakeholder roundtable discussions the committee held and notes the panel is sending letters to CMS to discuss efforts to reduce provider burden with respect to hospitals; post-acute care (PAC); physician and ancillary services; and rural health care. According to the report, the committee heard about major PAC issues including: Reducing burdens based on arbitrary numbers set by the federal government (e.g., the 25 percent rule for LTCHs, which the committee was pleased to CMS eliminate in FY 2019); removing barriers that get in the way of training and staffing of health care professionals; improving engagement, education and transparency between CMS and PAC providers; improving and streamlining certain billing processes and documentation requirements; increasing flexibility in correcting minor errors in claim submissions; and improving the flexibility for certain health care services and requirements. Finally, the report states that the committee will continue to explore legislative solutions looking ahead to 2019. On September 4, the committee sent three separate letters to CMS encouraging specific recommendations for hospitals, 6

AMRPA Magazine / October 2018

PAC providers and physicians. In the PAC-specific letter to CMS, the committee encourages the agency to facilitate more engagement with inpatient rehabilitation facilities (IRFs) through recurring Open-Door Forums (ODFs). House Energy and Commerce Subcommittee Analyzes SNFs On September 6, the House Energy and Commerce Oversight and Investigations Subcommittee examined nursing home quality and safety by addressing reports of abuse, neglect and substandard care occurring at Skilled Nursing Facilities (SNFs) participating in the Medicare and Medicaid programs. Subcommittee members heard testimony from the Government Accountability Office (GAO); a Regional Inspector General with HHS; and Dr. Kate Goodrich, director of the Center for Clinical Standards and Quality and Chief Medical Officer at CMS. Ruth Ann Dorrill, the Regional Inspector General, testified that, “Decades of OIG work on nursing homes has uncovered widespread problems in providing safe, high-quality care and reporting problems when they occur. We found that one in three Medicare residents in skilled nursing facilities experienced harm from the care provided, and half of these harm events were preventable.” John Dicken with the GAO testified that since an October 2015 GAO report found mixed results in nursing home quality, CMS had made progress on GAO’s recommended oversight activities, but had not monitored the potential effect of these modifications on nursing home quality oversight. Goodrich discussed how CMS had improved its oversight of nursing home facilities and how CMS takes allegations of abuse and mistreatment of nursing home residents very seriously. Subcommittee Chair Gregg Harper (R-MS) confirmed that the subcommittee will continue its work examining whether the federal government is meeting its obligations to ensure that residents in nursing homes across the country are free from abuse and are receiving the quality of care they deserve. MedPAC Continues to Examine Unified Payment System On September 6, 2018, the Medicare Payment Advisory Commission (MedPAC) held a session to discuss Medicare’s statutory and regulatory requirements under a unified payment system for post-acute care (PAC PPS). Among the commission’s recommendations for a unified PAC PPS, MedPAC has called for aligning program requirements for PAC providers. Currently, the four settings have distinct requirements, including requirements for benefit coverage in each setting; conditions of participations (COPs) for Medicare providers; and facility criteria for inpatient rehabilitation facilities (IRFs) and long-term care hospitals (LTCHs). Staff discussed a new approach to aligning requirements that would establish general and specialized requirements as separate tiers. The first tier would include common requirements for institutional and home health PAC providers that treat typical patients. These would include general requirements for institutional PAC providers. A key issue would be aligning clinical supervision and nursing requirements. Additionally, the commission could require home health agencies to have a medical director. A second tier would include more specialized, condition-specific requirements for providers to treat categories of patients with specific care needs. Staff also discussed potential policies that would help ensure appropriate PAC use in a unified payment system, such as maintaining the homebound requirement for home health and extending the three-day rule

to other settings. The latter policy may exempt accountable care organizations (ACOs) and permit observation days to count towards the three-day requirement. Commissioner Warner Thomas pointed to the importance of ensuring care quality and called for the commission to think about aligning PAC providers on readmissions and length of stays. Staff stated that they have always envisioned that there would be readmissions penalties and other incentives as part of a unified PAC PPS. Commissioner David Grabowski stated that he supports the basic framework of the policies presented and likes the idea of expanding the three-day rule to other settings. He added that the commission should figure out how to treat bundled payments under this framework. Commissioner Jaewon Ryu stated that it makes sense to apply the three-day rule to IRFs and LTCHs, while adding that this would seem to push the system toward bundles. HHS OIG Requests Stakeholder Input on Stark Laws On August 24, the HHS Office of Inspector General (OIG) issued a Request for Information (RFI) seeking input on ways to modify or add new safe harbors to the anti-kickback statute in order to remove barriers to care coordination and value-based payment. The RFI states that the department continues to grapple with how to balance additional flexibility for industry stakeholders

to provide efficient, well-coordinated, patient-centered care with protections against the harms caused by fraud and abuse. There is particular interest in feedback from stakeholders on: (i) the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements designed to promote care coordination and value; (ii) the need for new or revised safe harbors and exceptions to the definition of “remuneration” under the beneficiary inducements CMP to promote beneficial care coordination, patient engagement, and value-based arrangements; and (iii) terminology related to alternative payment models, value-based arrangements, and care coordination. As election day looms, congressional activity will take a hiatus as members spend their time in their home districts and states. Therefore, we strongly encourage you to reach out to your Senate and House elected officials as they may be interested in visiting hospitals and seeing constituents while out on the campaign trail. This will help lay the groundwork for what is expected to be a very active post-election lame duck session. The AMRPA team stands ready to assist you in any way — please do not hesitate to be in touch. Thank you for seizing the opportunity to educate members and candidates about the unique capabilities and role of IRFs in the continuum of care.

AMRPA Mourns the Passing of Dale Eazell It is with deep regret that AMRPA reports the passing of founding AMRPA Board Chair Dale Eazell. Dale was the former CEO of Casa Colina Hospital in California from 1973 until 1998, and drove the hospital to regional and national prominence during his tenure there. Dale received the AMRPA Chairman’s Award earlier this year, which conferred association-wide recognition and appreciation for his leadership, dedication and strong advocacy in support of the medical rehabilitation field. Dale was also instrumental in funding the ARA Research Institute, which has raised several million dollars to research the benefits of medical rehabilitation. If you would like to honor Dale’s commitment to his charities, memorial donations may be made to “Bridges to Home for Dale” St. Anthony’s Catholic Church, 2110 N. San Antonio Ave., Upland, CA 91784, or to Casa Colina Foundation, 255 E. Bonita Ave., Pomona, CA 91767 in memory of Dale Eazell.

AMRPA Magazine / October 2018

AMRPA Strongly Opposes Proposed RAC Issue—IRF Stays: Medical Necessity

AMRPA recently submitted strong comments to CMS’ proposal to have Recovery Audit Contractors, once again, target inpatient rehabilitation hospitals and units throughout the country for audits of medical necessity. Under the proposal, RACs would be permitted to audit in every state and would not be limited to certain geographic areas or patient diagnoses.

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

In its comments, AMRPA urged CMS to withdraw the proposed IRF audit issue for several important reasons: 1. The standard for IRF coverage used by Medicare contractors is inconsistent with the regulatory requirements; 2. New RAC audits would be duplicative of existing IRF audits conducted by other government entities, including other Medicare contractors; 3. The proposed RAC IRF issue is overly broad, not supported by any data showing a need for additional auditing of specific diagnoses, and amounts to a fishing expedition; 4. RACs have a history of shoddy auditing techniques and misapplication of appropriate medical necessity standards when auditing IRFs and should not be rewarded by, once again, being able to review these types of claims; and, 5. There is currently an extensive backlog of administrative law judge appeals at the Office of Medicare Hearings and Appeals (OMHA), which is the result of questionable auditing practices and application of inappropriate medical necessity standards by RACS. This new audit topic will likely prompt a large increase in appeals of IRF RAC denials, further placing extensive burdens on inpatient rehabilitation hospitals and units and exacerbating the lengthy delay for hearings from administrative law judges, which is currently the subject of federal litigation. “Goldilocks” Standard for Coverage is Incorrect and Unrealistic In recent meetings between AMRPA representatives and CMS officials, CMS has referred to IRF coverage as the “Goldilocks” standard. This reference is apparently meant to convey that Medicare beneficiaries who are referred to IRF care must be sick enough to require an inpatient hospital level of care, but not too sick to be unable to participate in a relatively intense therapy program on a daily basis. This is an exceedingly narrow interpretation of the medical necessity requirements for IRFs under the Medicare program and is the reason IRFs have been targeted by auditors and have relatively high initial denial rates from Medicare contractors. AMRPA’s members’ experiences, however, have shown that as many as 80 percent of denied IRF claims

AMRPA Magazine / October 2018

are overturned within the first three levels of the administrative appeals process, demonstrating that adjudicators disagree with the overly restrictive “Goldilocks” interpretation of the IRF coverage regulation. In its comment letter to CMS, AMPRA took the opportunity to describe the history of Medicare coverage requirements for IRF care. Prior to 2010, the determination of Medicare coverage for IRF services focused on whether the services and location were reasonable and necessary and listed eight criteria that IRFs and CMS auditors could use as guideposts when assessing Medicare coverage. Medicare auditors frequently second-guessed physician judgments under the pre-2010 standards. RACs used the coverage criteria to override significant numbers of physician decisions to admit patients to IRFs. Using non-physician clerical staff, RACs routinely asserted that patients “could have been treated in a less intensive setting, such as a skilled nursing facility.” IRFs found themselves defending the care that they provided based on comparisons to an idealized skilled nursing facility (SNF), which rarely, if ever, existed in practice. CMS issued new coverage regulations for IRF services in 2010, which are still applicable today. These regulations emphasize the admitting physician’s judgment, documentation and process.1 IRF coverage is determined “at the time of admission,” based on a rehabilitation physician’s reasonable expectations regarding the patient’s need for intensive, multidisciplinary therapy services under the supervision of the rehabilitation physician, and with the assistance of an interdisciplinary care team, in order to participate in and achieve a significant benefit from those therapy services.2 The regulation emphasizes the physician’s judgment when admitting a patient to an IRF and does not create blackand-white coverage rules that can be applied mechanically by auditors, especially auditors that do not have sufficient specialty training in rehabilitation. Each Medicare patient treated in an IRF must meet strict medical necessity coverage criteria. To be covered in an IRF, the patient must need an interdisciplinary approach to care and be stable enough at admission to participate in intensive rehabilitation. In addition, there must be a “reasonable expectation” that the patient will need multidisciplinary therapy, intensive rehabilitation, and supervision by a rehabilitation physician.3 IRFs are exposed to perhaps the most detailed and specific medical necessity requirements of any post-acute care provider. The documentation requirements to demonstrate medical necessity are formidable and create major burdens for providers. The 2010 regulations and guidance were designed to address the normative judgments and ambiguity that existed before 2010. The “Goldilocks” standard improperly applies the coverage regulation. The regulation requires that the patient be “sufficiently stable,” which necessarily means that the patient will be healthy enough to participate in intensive rehabilitation. It is inappropriate to deny coverage to patients who are “not sick enough” because the regulation does not require that they be sick at all. Requiring some minimal level of instability or medical

// Unfortunately, RACs have proven incapable of grappling with the complexities of rehabilitation care. Instead, they mechanistically apply the inappropriate “Goldilocks” standard, a standard that virtually guarantees that coverage will be routinely denied, thus maximizing the RAC’s contingency fee. complication at the time of admission ignores the role of the rehabilitation physician in managing the rehabilitation program. A patient may have medical comorbidities or the potential for medical complications that require a rehabilitation physician to oversee the intensive rehabilitation program to ensure that the patient does not suffer complications as a result of the program. Moreover, a patient may have complex rehabilitation needs that warrant a rehabilitation physician’s supervision of the program even in the absence of medical comorbidities or complications. Likewise, the “too sick” side of the “Goldilocks” shorthand is also inappropriate. A physician may, at admission, reasonably believe that the patient will be able to participate in the intensive rehabilitation program, and the patient nonetheless experiences complications after admission that prevent full participation in the program for part of the stay. The regulations acknowledge this possibility by permitting a patient to satisfy the so-called “three-hour rule” by participating in 15 hours of therapy in a week rather than in three hours of therapy over five days. CMS also recognizes a “brief exceptions” policy in which IRF care is covered when the patient cannot participate in three hours of therapy. Unfortunately, RACs have proven incapable of grappling with the complexities of rehabilitation care. Instead, they mechanistically apply the inappropriate “Goldilocks” standard, a standard that virtually guarantees that coverage will be routinely denied, thus maximizing the RAC’s contingency fee. New RAC Audits Would be Duplicative of Existing Audits of IRFs Multiple Medicare Administrative Contractors (MACs) routinely audit inpatient rehabilitation hospitals and units across the country and have been doing so for years. The Supplemental

AMRPA Magazine / October 2018

Medical Review Contractor (SMRC) has conducted widespread audits of IRFs over the past two-year period. In addition, the Office of Inspector General (OIG) added IRF care to its work plan in recent years and has been undertaking numerous IRF audits across the country. In responding to CMS, AMRPA stated, “With at least three government entities or contractors auditing IRFs, additional auditing by Recovery Audit Contractors would be duplicative, confusing and exceedingly burdensome on inpatient rehabilitation hospitals and units.” The amount of time and attention IRFs must give to existing auditing activity directly impacts the amount of time and focus front-line providers can devote to treating patients in real time. The Scope of the IRF Issue is Overly Broad In its response to CMS, AMRPA also argued that the proposed audit request is overly broad in scope. CMS proposes to permit RACs to audit the following issue: “Inpatient rehabilitation stays meeting requirements to be considered reasonable and necessary.” The audits would be complex reviews that, by definition, require providers to respond to multiple documentation requests by researching the patients’ medical files and transmitting them within a prescribed timeframe to the RAC for inspection. These reviews would be conducted in all states, thereby potentially impacting all IRFs nationwide. AMRPA believes this proposed issue is far too broad in scope, not linked to any data supporting the need for additional auditing of specific diagnoses, regions of the country, or specific states, and amounts to a fishing expedition. Considering the financial incentives the RACs have to target high dollar claims in order to maximize their contingency fees, AMRPA asserted that this proposed RAC issue would create an “open season” on IRFs. If CMS decides to grant approval for the RACs to audit IRFs, it should limit these audits to specific diagnoses or areas of the country where the data demonstrates IRF claims should be legitimately subject to audit, argued AMRPA. The Issue Should Not Be Approved Because RACs Have Not Proven They Can Accurately Audit IRFs AMRPA asserted that RACs have a highly questionable record of auditing IRF claims. From the inception of the program, RACs have proven incapable of grappling with the complexities of IRF admissions. RACs have incorrectly denied tens of thousands of IRF claims, which IRFs have had to appeal through an onerous, lengthy and hopelessly backlogged appeal system. In the end, IRFs have been vindicated as demonstrated by extremely high reversal rates in favor of providers. But, AMRPA warned, not all the damage can be undone. AMRPA stated that these reckless RAC audits forced IRFs to expend significant resources on audits and appeals, hire consultants and outside counsel, hire additional administrative staff, divert members of the rehabilitation team away from direct patient care, and forego payment for services already rendered during the multi-year appeals process. As a result, AMRPA asserted, RAC audits have had a chilling effect on IRF admissions that impacts the availability of care to the most vulnerable Medicare beneficiaries. CMS should not repeat its past mistakes. 10 AMRPA Magazine / October 2018

Instead, argued AMRPA, CMS should withdraw the proposed RAC issue for IRF services. AMRPA asserted that RACs have a poor track record of auditing IRFs and that they have failed to hire competent medical staff with experience in inpatient hospital rehabilitation. The decision to admit a patient to an IRF is a complex medical judgment. The admitting physician must weigh the patient’s rehabilitation and medical needs to assess whether the patient is appropriate for the IRF setting. Most physicians are incapable of making this judgment, which is why CMS requires that IRFs provide care from physicians with specialized training and experience in rehabilitation.4 In AMRPA’s experience, RAC reviewers are rarely, if ever, physicians with specialized training or experience in rehabilitation. Rather, RAC reviewers tend to be nurses or other clinicians with scant exposure to the IRF clinical setting of care. These reviewers typically undervalue the complexities of treating rehabilitation patients in real time as problems present. Even with the latest updates to the RAC processes, AMRPA stated that it is extremely skeptical that the defects will be cured in the most recent round of RAC contracts. CMS has now begun withholding RAC contingency fees until after the second level of appeal.5 However, AMRPA members report many of their successful appeals occur at the third level of appeal, which means RACs will still be incentivized to aggressively deny claims. In addition, CMS is requiring a minimum accuracy rate of 10 percent, but only through the first level of appeal, so RACs will not be held accountable for their accuracy for overturned denials at the second level of appeal and beyond. The RAC contingency fee structure creates incentives that are particularly inappropriate for auditing IRF claims, asserted AMRPA. Because IRFs provide intensive rehabilitative care and medical management, IRF reimbursement is higher than most Medicare claims, making IRFs a prime target for RACs hoping to maximize their contingency fee recoveries. Likewise, auditing IRFs requires highly skilled and trained rehabilitation physicians who understand the nuances of inpatient rehabilitation care. AMRPA expressed doubt that RACs will expend the resources necessary to retain rehabilitation physician reviewers. Without this expertise, asserted AMRPA, RACs will continue to assess highly complex and specialized rehabilitation patients with medical generalists and other professionals with limited engagement with rehabilitation. The Issue Should Be Withdrawn Because RAC Audits of IRF Claims Will Increase the ALJ Backlog AMRPA argued that now is the wrong time to permit new RAC audits of IRF claims. As already stated, RACs are not well-suited to auditing IRFs, and permitting these audits will only exacerbate the extensive backlog of administrative law judge appeals at the Office of Medicare Hearings and Appeals (OMHA). CMS has recently made progress toward reducing the backlog, and it should not undermine those efforts now. As recently as July 2014, OMHA had a backlog of more than 800,000 appeals.6 This backlog was largely driven by the RAC program.7 The DC Circuit Court of Appeals found in the American Hospital Association v. Azar case that “the RAC

program has contributed to a drastic increase in the number of administrative appeals.”8 The court noted that “some alreadyfiled claims could take a decade or more to resolve.”9 The court specifically addressed the plight of IRF patients and found that the ALJ backlog is “having a real impact on “‘human health and welfare’” of IRF patients.10 These arguments were made to the court by AMRPA’s sister organization, the Fund for Access to Inpatient Rehabilitation (FAIR Fund), a common legal fund that filed a number of amicus curiae— “friend of the court”— briefs in the AHA case. The court thus held that CMS was violating a statutory requirement to decide ALJ appeals within 90 days.11 This litigation continues today. CMS recently reported important progress on the backlog. In a status report to the U.S. District Court for the District of Columbia, CMS projected that the backlog would be down to 426,594 appeals by the end of fiscal year 2018. Congress has appropriated $182.3 million for OMHA to address the backlog, a major increase in funding from the previous fiscal year. As a result, CMS believes that it can clear the ALJ backlog by the end of fiscal year 2022. Assuming this level of federal resources continues to be appropriated in the coming years, argued AMRPA, additional funding alone will not clear the backlog, as CMS has admitted in its filings to the D.C. District Court. CMS also hopes to remove cases from the backlog through its various settlement initiatives and has informed the court that “CMS is actively negotiating with IRF representatives” on a global settlement of nearly “12,000 IRF appeals” in the backlog.

The ALJ backlog is not yet cleared and it will take several more years to do so. AMRPA stated that it would be wholly irresponsible for CMS to unleash RACs on the IRF field while nearly half a million ALJ appeals remain in the queue. If this RAC issue is approved, the number of IRF appeals will certainly increase. Approving this RAC issue would also run contrary to CMS’s settlement discussions with the IRF field and its representations to the D.C. District Court that it is acting in good faith to reduce the ALJ backlog and to come into compliance with its statutory obligation to decide appeals within 90 days. Therefore, AMRPA recommended strongly that CMS withdraw the proposed RAC IRF issue. A decision is expected from CMS in the next several weeks or months. END NOTES 1. 74 Fed. Reg. 39,762 (Aug. 7, 2009) (final rule); 42 C.F.R. § 412.600 et seq. 2. 42 C.F.R. § 412.622(a)(3); Medicare Benefits Policy Manual (MBPM), ch. 1, § 110.2. 3. 42 C.F.R. § 412.622(a)(3), (a)(5). 4. 42 C.F.R. § 412.622(a)(3)(iv). 5. CMS, Recovery Audit Program Improvements - Completed (as of October 31, 2016), https://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/ Downloads/Recovery-Audit-Program-Improvements-November-24-2017.pdf. 6. Am. Hosp. Ass’n v. Burwell, 812 F.3d 183, 187 (D.C. Cir. 2016). 7. Id. at 186-87. 8. Id. at 187. 9. Id. 10. Id. at 193 11. Id. at 192 (quoting Telecommunications Research & Action Center v. FCC, 750 F.2d 70, 80 (D.C.Cir.1984) and citing AMRPA amicus brief at 28). 12. Cumberland County Hospital System v. Price, No. 5:15-cv-319-D, 2017 WL 1048102, at *11-*14 (E.D.N.C. Mar. 1, 2017).

RAC audits of IRFs would also contribute significantly to the backlog because a federal court recently held that the MBPM inappropriately requires documentation that is not present in CMS regulations.12 Therefore, until CMS can reconcile the subregulatory guidelines used by RACs with its regulations, argued AMRPA, IRFs will continue to appeal to the ALJ level of appeal and receive positive outcomes.

AMRPA Magazine / October 2018 11

A Review of the Sections B, C, GG and H IRF-PAI Quality Indicators

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

Since October 1, 2016, the Inpatient Rehability Facility Patient Assessment Instrument (IRF PAI) has included a large number of quality indicators. Beginning in October 2020, we can expect the IRF PAI to look even more different. At that time, the FIM instrument that has been part of our Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) payment system since 2002 will be replaced by many of the section GG items for the assignment of case mix groups (CMGs). Now is the perfect time to review some of the nuances associated with the quality indicator items and make a few recommendations regarding their implementation. Section B has two questions related to expressing ideas and wants and understanding verbal content. These items are significant because, while we collect similar information with our cognitive FIM questions, the scales are different. Section C introduces a new cognitive tool called the Brief Interview for Mental Status (BIMS). It is a five-question test conducted at admission. If your patient is unable to complete the BIMS, a different set of questions is offered to measure the patientâ&#x20AC;&#x2122;s memory and recall ability. Both sections B and C are completed only with the admission assessment. The instructions indicate that the items should be evaluated across a three-day assessment reference period. However, most people are including these items in the nursing and therapy assessment. Collecting the answers once provides enough information to complete the IRF-PAI. Furthermore, completing the BIMS tool has been a challenge for providers because of timing. Most providers elect to have the occupational therapists test the BIMS unless the patient was being seen by speech therapy. However, others have incorporated BIMS in the nursing assessment. I believe the best approach for BIMS is to ask the nurses to complete the assessment to safeguard against missing information in cases where patients are discharged back to acute within hours and a therapy evaluation was not completed. Prior Functioning (question GG0100 A-D) asks for information in the areas of self-care, indoor mobility, steps and functional cognition. Prior Device Use (question GG0110 A-Z) is another new section. These questions were added to the eRehabDataÂŽ PAS tool because, in our experience, most clinical liaisons are already asking them. If they are completed in the PAS tool, the responses pull forward to the IRF-PAI, but the PPS coordinator should verify the accuracy of the information when finalizing the admission IRF-PAI.

12 AMRPA Magazine / October 2018

The Self-Care and Mobility items (questions GG0130 A-H and GG0170 A-SS) under the Functional Abilities and Goals section differ from the FIM section in several ways. For example, the scale used to reflect the patient’s level of performance is not the same. Instead of a seven-point scale that requires us to report the patient’s lowest level of function in the first three days of their stay, the new measures use a six-point scale that reflects the patient’s usual performance across the first three days of the stay. At admission, an admission score is required for the FIM items according to the seven-point scale and a discharge goal for each is optional. The section functional items require an admission score, and a discharge goal for at least one item, according to the six-point scale. The Self-Care items include eating, oral hygiene, toileting hygiene, bathing (in a shower or tub), upper body dressing, lower body dressing, and putting on/taking off footwear. The Mobility items include rolling left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfers, toilet transfer, car transfer, walking over different distances including turns and an uneven surface, steps, and wheelchair/scooter use. Therapists are the best suited for completing these items as they already have some of the items built into their evaluation templates. Additionally, check the Occupational Therapy and Physical Therapy assessments for these questions before you build a separate form that adds to the nurses’ workflow. You should add a place to your documentation for therapists to set goals since you will be setting goals for at least one item in section GG.

definition of the items and include reminders in order to capture the many nuances. Because these items call for reporting the patient’s usual performance across the first three days of the stay, you should also check nursing assessments for notes regarding the patient’s performance in those areas. If, for example, the nurse documents on burden of care for bathing, that input should then be considered when assigning the functional score for that item. Section H includes two questions about bladder and bowel incontinence. These items should be completed based on a review of the first three days of the stay. This section might be tricky if it is added to the EMR to be answered on day three only, because the nurse completing the question might be working with the patient for the first time. Additionally, as you consider your questions or screens for this item, determine if you can build incontinence into a panel or flowsheet that the nurse can easily access to gather the necessary data for completing this item. Another option is to make this an item that the PPS coordinator answers based on the daily nursing documentation. We will certainly be discussing the quality indicators in more detail as October 1, 2020, approaches, but a refresher on some of the basics is a good place to start. Make sure to start discussing your plans for the upcoming changes starting in early 2019.

Most providers elected to add an additional data collection tool for the section GG items. Since you already have a data collection tool, you’re in a good position to include nursing in the assessment of these items as you move forward. However, review the tool for triggers that will help the providers understand the

AMRPA Magazine / October 2018 13

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

14 AMRPA Magazine / October 2018

Medicare Payments Continue to Expand Payments Over Costs by State

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

Highlights: »»

States continue to improve Medicare payments over costs.

AMRPA examines the rate files that Medicare publishes each year in conjunction with the final Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) rule and has done so since at least 2013. The rate files give provider numbers, the number of Medicare discharges from one or two years prior, cost to charge ratios, wage index, rural status, disproportionate share, census region, teaching status, whether freestanding, the prior year’s estimated measure of the average weight per discharge, costs per case, estimated prior year simulated payment including outliers, and similar estimated payments for the fiscal year in question. We then total the estimated payments for each state and the total estimated costs and looked at which was higher, cost or payments.

// In 2013, only 10 states showed a positive difference between payment and cost. However, when we did the analysis this year based on the rate setting files published with the FY 2019 IRF PPS final rule, 20 states were in the red and the balance of the states (30) had payments greater than cost (states in green).

The initial year, 2013, showed the majority of states were in the red, meaning that there was a negative difference between their Medicare payments and cost (Medicare costs exceed payments). In 2013, only 10 states showed a positive difference between payment and cost. However, when we did the analysis this year based on the rate setting files published with the FY 2019 IRF PPS final rule, 20 states were in the red and the balance of the states (30) had payments greater than cost (states in green). Three states had switched from red to green and, curiously, three states had switched from green to red. The continued switch from red to green may reflect the overall increase in IRF payment over time as well as the increase in the severity of the case mix index— the mix of patients that inpatient rehabilitation hospitals and units are admitting. If you have questions, contact Mimi Zhang, Senior Policy and Research Analyst (mzhang@amrpa.org), or Carolyn C. Zollar, JD, Executive Vice President for Policy Development and Government Relations (czollar@amrpa.org)

AMRPA Magazine / October 2018 15

Difference Between Medicare Payment and Provider Cost for FY 2019 Based on FY 2019 IRF PPS Final Rule (includes outlier payments) WA MT OR

ID WY

MD WV

NH MA CT RI

NJ DE

KY NC

SC MS

MI PA

IL CO

LA FL

Payment is lower than cost Payment is higher than cost Changes from FY 2018 to FY 2019 GA, SD, IN WY, ME, NC

Source: CMS FY 2019 IRF PPS Final Rule Rate Setting File © AMRPA, Washington, DC, 2018

States with a Negative or Positive Difference Between Payment Map of the United States Showing States with a Negative Difference Between Payment and Cost for FY 2013 (with outliers) and Cost for FYor Positive 2013 (with outliers)

Legend

States with a negative difference between payment and cost States with a positive difference between payment and cost States with a positive difference between payment and cost for FY 2013, but by FY 2014 will be negative or less than $30 from being negative.

16 AMRPA Magazine / October 2018

Source: CMS FY 2013 IRF PPS Final Rule Rate Setting File © AMRPA, Washington, DC, 2013

IRF PAI and Quality Reporting Changes Starting October 2018

Mimi Zhang, Senior Policy and Research Analyst

Highlights: »»

The new Drug Regimen Review measure adds assessment items to the IRF PAI.

»»

The IRF QRP pressure ulcer measure changed in how provider performance is calculated and risk-adjusted.

As readers are likely aware, the Inpatient Rehabilitation Facility Prospective Payment Program (IRF PPS) final rule for federal fiscal year (FY) 2019 did not introduce additional quality measures or reporting requirements to the IRF Quality Reporting Program (IRF QRP) starting October 1, 2018 (FY 2019). In fact, the Centers for Medicare and Medicaid Services (CMS) pared back reporting requirements by retiring two IRF QRP measures in this year’s rule: 1) National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716), and 2) Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680). Both removals are effective starting October 1, 2018. However, there are two major changes to the IRF QRP and the IRF Patient Assessment Instrument (IRF-PAI), finalized in prior years’ rulemakings, that also go live on October 1, 2018. This article summarizes those changes. Inpatient rehabilitation hospitals and units (IRH/Us) should review and understand how the changes may impact their clinical workflows, performance on certain Medicare quality measures, and compliance with the IRF QRP. Drug Regimen Review Measure In the FY 2017 IRF PPS final rule, CMS added the measure Drug Regimen Review Conducted with Follow-Up for Identified Issues (DRR) to the IRF QRP effective October 1, 2018. DRR is an assessment-based process measure adopted to meet the requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act domain of medication reconciliation. As an IMPACT-mandated item, the DRR measure has been adopted across post-acute care settings; for instance, home health agencies began reporting the measure in January 2017 and long-term care hospitals began reporting in July 2018. A provider’s performance on the DRR measure is calculated based on assessment items from IRF-PAI Section N: Medications, as shown in the tables below. These are new sections and items to both the admission and the discharge portions of IRF PAI version 2.0 (effective October 1, 2018).

AMRPA Magazine / October 2018 17

Admission assessment: Section N – Medications Section N

Medications

N2001. Drug Regimen Review Did a complete drug regimen review identify potential clinically significant medication issues? 0. No – No issues found during review  Skip to O0100, Special Treatments, Procedures, and Programs 1. Yes – Issues found during review  Continue to N2003, Medication Follow-up 2. NA – Patient is not taking any medications  Special Treatments, Procedures, and Programs N2003. Medication Follow-up Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/ recommended actions in response to the identified potential clinically significant medications issues? 0.

No Yes

Discharge Assessment: Section N – Medications Section N

Medications

N2005. Medication Intervention Did the facility contact and complete physician (or physiciandesignee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the admission? 0. 1.

Discharge item N2005: Identifies if the facility contacted a physician (or physician-designee) completed all physician- (or physician-designee)-prescribed/ recommended actions by midnight of the next calendar day each time potential or actual clinically significant medication issues were identified throughout the stay. The DRR measure reports the percentage of patient stays in which a drug regimen review was conducted at the time of admission, and timely follow-up with a physician occurred each time potential and actual clinically significant medication issues were identified throughout the patient’s stay. The measure does not have any denominator exclusions and it is not risk adjusted or risk stratified. Pressure Ulcer Measure Beginning October 1, 2018, the measure Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) was replaced with a revised pressure ulcer measure, Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: I022.01). This change was adopted in the FY 2018 IRF PPS final rule. The replacement measure, Changes in Skin Integrity PostAcute Care: Pressure Ulcer/Injury (CMS ID: I022.01), will be publicly reported on the IRF Compare website by October 2020, according to CMS. The previous measure will continue to be publicly reported on IRF Compare until new quarterly data is no longer available to report. The two measures will not be publicly reported on IRF Compare at the same time.

Yes

NA – There were no potential clinically significant 2. medication issues identified since admission or patient is not taking any medications.

According to CMS, drug regimen review in post-acute care is “generally considered” to include: Medication reconciliation: A review of all medications a patient is currently taking; and Drug regimen review: A review of the drug regiment to identify and, if possible, prevent clinically significant mediation issues. CMS describes the purpose of the assessment items as follows: Admission item N2001: Identifies if a drug regimen review was conducted upon admission, and if the clinician identified any potential or actual clinically significant medication issues. Admission item N2003: Identifies if the facility contacted a physician (or physician-designee) and completed all physician- (or physician-designee)-prescribed/ recommended actions by midnight of the next calendar day in response to all potential or actual clinically significant medication issues identified upon admission.

18 AMRPA Magazine / October 2018

The table below provides additional information regarding the data collection and when the performance reports will be displayed in CASPER for provider review. Pressure Ulcer Measure

Data Collection

Review and Correct Reports

Quality Measure (QM) Reports

Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) (CMS ID: I001.02)

Last Quarter of Data Collection: Q3 2018 (07/01/2018 – 09/30/2018)

Last Quarter End Date Display: Q3 2018 (10/01/2017 – 09/30/2018)

Last Report End Date Display: 09/30/2018 (10/01/2017 – 09/30/2018)

Changes in Skin Integrity PostAcute Care: Pressure Ulcer/ Injury (CMS ID: I022.01)

Initial Quarter of Data Collection: Q4 2018 (10/01/2018 – 12/31/2018)

Initial Quarter End Date Display: Q1 2019 (01/01/2019 – 03/31/2019)

Initial Report End Date Display: 09/30/2019 (10/01/2018 – 09/30/2019)

Table source: Inpatient Rehabilitation Facility Quality Reporting Program Measure Calculations and Reporting User’s, Manual Version 3.0. Prepared by RTI International for CMS. Current as of October 1, 2018.

Although on their face the two pressure ulcer measures assess the same outcome (new or worsened pressure ulcers/injuries), there are several key differences between the measures: The measures use different patient assessment items. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) (CMS ID: I001.02) is calculated using discharge M0800 items, while the Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: I022.01) is calculated using discharge M0300 items. As of October 1, 2018, the M0800 items will no longer be collected as part of the IRF-PAI. The new measure includes unstageable pressure ulcers in the measure numerator. The numerator for Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: I022.01) includes discharge items to include new or worsened unstageable pressure ulcers documented by the following IRF PAI items: Unstageable – Non-removable dressing/device (M0300E1 and M0300E2); Unstageable – Slough and/or eschar (M0300F1 and M0300F2); and Unstageable – Deep tissue injury (M0300G1 and M0300G2). The new measure is calculated using a subtraction method to determine inclusion in the numerator. Inclusion in the numerator of Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: I022.01) is determined by subtracting discharge item pairs for each type of pressure ulcer (e.g., Stage 2 [(M0300B1) - (M0300B2)] >0, Stage 3 [(M0300C1) - (M0300C2)] >0). One of the exclusion criteria for the new measure is different, to reflect changes in the data needed to calculate the measure. For the Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) (CMS ID: I001.02) measure, a patient stay-level record was excluded if data on new or worsened Stage 2, 3, and 4 were missing at discharge, based on discharge M0800 items. For the Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: I022.01) measure, this is expanded to add unstageable pressure ulcers, including deep tissue injuries, missing at discharge, and is based on discharge M0300 items.

Measure item names have changed. The items to be collected starting October 1, 2018, reflect current pressure ulcer terminology. The term “injuries” has been added to items: M0300, M0300A, M0300E–M0300E2, and M0300G– M0300G2 and the term “suspected deep tissue injury in evolution” has been replaced with “deep tissue injury” in items M0300G and M0300G1. The assessment items used to risk adjust the measure (specifically, to indicate the functional limitation covariate) have changed: FIM™ item 39I (Transfers: Bed, Chair, Wheelchair) was used to determine the functional limitation covariate for each patient stay in the Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) (CMS ID: I001.02) measure. For the Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: I022.01) measure, GG0170C (Lying to Sitting on Side of Bed) at admission is used to determine the functional limitation covariate for each patient stay. The item used to indicate the bowel incontinence covariate has changed. Item 32 (Bowel Frequency of Accidents) was used to determine the bowel incontinence covariate for each patient stay in the Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) (CMS ID: I001.02) measure. For the Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: I022.01) measure, H0400 (Bowel Continence) is used to determine the bowel incontinence covariate for each patient stay. CMS has conducted training on DRR and the pressure ulcer measure through live training events, and webinars or open door forum calls, and as recently as August and September. Training materials such as presentation slides, audio and video recordings, and other IRF QRP resources can be found at https:// www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/IRF-Quality-Reporting/IRF-Quality-ReportingTraining.html.

AMRPA Magazine / October 2018 19

AMRPA Submits Comments to CMS on Modernizing Stark Self-Referral Regulations Editor’s Note: On August 24, 2018, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Centers for Medicare and Medicaid Services (CMS) in response to its Request for Information (RFI) on modernizing the physician self-referral regulations, commonly referred to as “Stark.” This article is an abbreviated version of the comments submitted by AMRPA. The complete comment letter is available at www.amrpa.org.

Dear Administrator Verma: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we appreciate the opportunity to respond to the Centers for Medicare & Medicaid Services’ (CMS) Request for Information (RFI) on the physician self-referral law (“Stark”) published in the Federal Register on June 25, 2018. AMRPA is the national trade association representing more than 625 freestanding inpatient rehabilitation hospitals and rehabilitation units of general hospitals (IRH/Us, but referred to by CMS as “IRFs”), outpatient rehabilitation service providers, long-term care hospitals (LTCHs), and several skilled nursing facilities (SNFs). In 2016, inpatient rehabilitation hospitals and units served 350,000 Medicare beneficiaries with more than 391,000 IRH/U stays. IRH/Us provide hospital-level care, which is significantly different in intensity, capacity and outcomes from care provided in non-hospital post-acute care (PAC) settings. Most patients in an IRH/U have one of 13 serious conditions, which include stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, brain injury and neurological disorders. Patients in an IRH/U are closely supervised by a physician, who also oversees patients’ overall rehabilitation treatment, which must include a minimum of 15 hours per week of therapy services. AMRPA members utilize this interdisciplinary approach to 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. IRH/Us are keenly aware of the impediments created by Stark. Most IRH/U patients are referred from an acute-care hospital due to a complex condition requiring interdisciplinary and intensive rehabilitation treatment. However, a patient’s treatment does not stop at discharge 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. IRH/Us and their physicians face the difficult task of monitoring compliance with Stark for both referrals for admission to the IRH/U as well as discharge from the IRH/U to a different setting. The rigid, strict-liability of Stark creates a presumption that any self-referral is fraudulent, which is inconsistent with the plethora of CMS’ initiatives to hold providers accountable for patients after they are discharged or leave a provider’s care. Unlike when Stark was created, many Medicare providers are now held accountable for the value of the care provided through one Medicare mechanism or another. Acute care hospitals, for example, submit measures to the Hospital Value Based Purchasing Program (VBP), which adjusts payment based on quality and cost metrics. In addition, Medicare providers, including IRH/Us, undergo frequent and rigorous audits to determine the medical necessity of the care provided at their hospitals. Further, many physicians within IRH/Us are now subject to the Merit-Based Incentive Program, which adjusts payment based on cost and quality measures. Due to multiple checks on the quality, value and medical necessity of care delivered to Medicare beneficiaries, it is no longer appropriate to presume a referral from which the physician may benefit was improper. In general, IRH/Us and other providers

20 AMRPA Magazine / October 2018

require much more flexibility to pursue legitimate value-based arrangements, both via models sponsored by Medicare and outside of Medicare, without risk of running afoul of Stark. This is why, as discussed more fully below, AMRPA recommends that CMS create a broad, bona fide value-based waiver for Medicare providers under Stark. This waiver would need to be widely applicable to all types of value-based payment arrangements due to the fact that current waivers are narrow and relatively ineffective. Coupled with our recommendation to provide more flexibility under Stark, AMRPA also recommends that CMS implement sufficient patient safeguards for any such changes. Any valuebased arrangement has inherent pressures to reduce spending and, in turn, drive patients toward less expensive and less intensive settings of care. This dynamic is particularly important for patients with disabilities and chronic illnesses whom IRH/ Us serve, because these incentives risk the denial of access to necessary and appropriate rehabilitative care. The medically complex patients treated in IRH/Us are always resource-intensive and in need of significant ongoing treatment and therapy to regain function, even after discharge from an IRH/U. Therefore, AMRPA recommends below that CMS proceed cautiously with Stark reforms in order to ensure that there is sufficient quality accountability and consumer protections for beneficiaries to prevent care stinting as a result of the financial incentives and cost pressures inherent in value-based arrangements. I. CMS Should Create a Bona Fide Value-Based Arrangement Waiver Under Stark. CMS already recognizes that many value-based initiatives, such as shared savings programs, run afoul of Stark and require waivers. This is why, for example, the agency issued waivers for participants in the Medicare Shared Savings Program (MSSP) and most of its other innovative payment models and demonstrations. However, these waivers are limited not only to a specific program, but also only to direct participants. This is restrictive in several ways. First, it means there is no waiver for hospitals trying to create value-based incentives for their providers outside of these specific Medicare programs. Second, even preferred providers who contract with an Accountable Care Organization (ACO) cannot utilize this waiver, since it is for only direct members of the ACO. This can present a problem for IRH/Us, which for other reasons may not be able to be directly included in the ACO, but nonetheless would like to offer its services as a preferred provider to ACO patients in a value-based arrangement. Instead of offering narrow Stark waivers for specific types of Alternative Payment Models (APMs), CMS should create a broad, bona fide value-based waiver under Stark. This waiver, which should be proposed and established through notice and comment rulemaking, would establish parameters for what constitutes a bona fide value-based arrangement that would create a safe-harbor from Stark violations. Within these parameters, CMS should lay out several permitted objectives of such an arrangement. Among other considerations, these objectives should include accountability for the quality and outcomes of patient care, as well as encouraging care management and coordination among providers.

The bona fide value-based waiver should apply to all value-based arrangements, whether as part of an APM, a demonstration under Medicare, or arranged independently among Medicare providers. Further, as discussed more fully below, the analysis of whether a relationship is valuebased should also include an evaluation of the safeguards to prevent stinting on patient care due to the financial incentives involved in the arrangement. Therefore, AMRPA recommends CMS create a broad, bona fide valuebased waiver to allow for legitimate value-based arrangements within the Medicare program. II. When Creating More Flexibility Under Stark, CMS Should Also Enhance Efforts to Prevent Stinting of Patient Care by Ensuring Accountability for Long-Term Functional Outcomes. As described above, AMRPA supports CMSâ&#x20AC;&#x2122; efforts to reform Stark regulations to improve the effectiveness of innovative, value-based approaches to care delivery. However, CMS should take great precaution to ensure any value-based arrangement that it sponsors or permits does not lead to stinting on patient care, particularly PAC. 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. Stinting on patient care is a particular risk in the PAC sector, where a treating physician must make a decision between discharge options with widely varying intensity of services, and thus widely varying costs. AMRPA members have found that as value-based payment arrangements with a disproportionate 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 ACOs under the MSSP. The Commission found that organizations have generated savings not through reducing unnecessary hospital readmissions, but largely by decreasing PAC utilization. This diversion of patients away from the more intensive settings of PAC is occurring in spite of recent clinical guidelines published by the American Heart Association and the American Stroke Association which recommend acute hospital-level care for post-stroke rehabilitation. It is also in spite of CMSâ&#x20AC;&#x2122; own research on the Bundled Payments for Care Improvement Initiative (BPCI) Model, which showed better functional outcomes for stroke patients treated at IRH/ Us when compared to other settings of PAC. 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 per-capita payment basis and thus bear risk for utilization, also show significant differences in access to IRH/U care. In its March 2017 Report to Congress, MedPAC found that MA enrollees are admitted to IRH/Us at approximately one-third the rate of Medicare fee-for-service beneficiaries in 2015, which is also consistent with previous yearsâ&#x20AC;&#x2122; data.

AMRPA Magazine / October 2018 21

Without proper accountability, it can be far too easy for providers to achieve “benchmark” performance on measures such as Medicare Spending Per Beneficiary (MSPB) by denying patients access to timely and intensive inpatient rehabilitation hospital services and diverting beneficiaries to less intense levels of PAC. It is also relatively easy to reduce PAC costs by limiting or restricting the amount, duration, and scope of rehabilitation services and devices available upon discharge from a facility. These risks are heightened when APMs and other value-based arrangements are not held accountable for functional and other outcomes. Ultimately, and as CMS knows, any short-term savings to Medicare through underutilization of PAC services are offset by significant unnecessary long term costs. Disability, lack of function, and hospital readmissions create far greater expenditures in the long term than any savings achieved through reduced payments in the shortrun. Less independent living, more sedentary lifestyles, greater dependence on home care, and greater reliance on mobility aids and equipment could be averted through timely, intensive and appropriate rehabilitation services and devices. Needless to say, the unquantifiable cost of these negative outcomes on a patient’s quality of life is even more dramatic. Therefore, as CMS considers reforming Stark regulations to help promote value-based arrangements, the agency should ensure the arrangements are truly quality enhancing ventures that have strong safeguards in place so patients can access medically necessary and appropriate care. To accomplish this, CMS should ensure that ample functional outcome measurement and quality accountability are

22 AMRPA Magazine / October 2018

included in any value-based program. This would, at a minimum, require providers to be held more accountable for the quality of care and outcomes for patients than the cost of care delivered. CMS should look skeptically upon any arrangements with too much of 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. In addition, CMS should consider requiring additional consumer protections for any beneficiaries being treated under a value-based arrangement. Such protections should include freedom of choice so that Medicare beneficiaries are permitted to seek treatment outside of the valuebased arrangement if they so desire, as well as a disclosure requirement that providers inform beneficiaries they are being treated as part of a value-based arrangement and have the option to seek treatment elsewhere using their Medicare coverage. AMRPA supports CMS efforts to find ways to eliminate impediments to value-based care created by Stark. However, value-based arrangements can create a concomitant risk of stinting on patient care. Therefore, AMRPA recommends CMS proceed cautiously with providing additional flexibility for value-based arrangements under Stark and ensure all arrangements contain sufficient safeguards to protect beneficiaries from being denied necessary care.

AMRPA Submits Recommendations to CMS Regarding CY 2019 Physician Fee Schedule, Quality Payment Program, and Medicare Shared Savings Program Proposed Rule Editor’s Note: On September 10, 2018, AMRPA submitted a formal response to the Centers for Medicare and Medicaid Services (CMS) Proposed Rule pertaining to the Quality Payment Program (QPP), Physician Fee Schedule (PFS) and Medicare Shared Savings Program (MSSP). This article is a summary of the recommendations submitted by AMRPA. The complete comment letter is available at www.amrpa.org.

Dear Administrator Verma: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we write in response to the proposed rule for the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (PFS), Quality Payment Program (QPP) and Medicare Shared Saving Program (MSSP) published in the Federal Register on July 27, 2018. AMRPA is the national trade association representing more than 625 freestanding inpatient rehabilitation hospitals and rehabilitation units of general hospitals (referred to by Medicare as inpatient rehabilitation facilities (IRFs) but hereinafter referred to as IRH/ Us). The vast majority of our members are Medicare participating providers and in 2016, inpatient rehabilitation hospitals and units served 350,000 Medicare beneficiaries with more than 391,000 IRH/U stays. AMRPA members also provide rehabilitation services across the continuum of care beyond the inpatient hospital, including hospital outpatient departments, comprehensive outpatient rehabilitation facilities (CORFs) and therapy clinics. As part of this continuum of care, our members submit claims under Part B of the Medicare program for a variety of services, including physician visits, physical therapy, occupational therapy services, speech-language pathology and a number of other elements of care. Rehabilitation is an essential component of recovery from a wide-array of injuries and illnesses, and it is important that CMS keep rehabilitation in mind when modernizing the Medicare program. AMRPA has pressing concerns about a number of rehabilitationrelated proposals in this rule, which are summarized in the first section of this letter before being more fully articulated in subsequent sections. We appreciate the opportunity to collaborate with CMS on these matters in order to ensure that the most effective and efficient rehabilitation services continue to be available for Medicare beneficiaries. The following is a summary of AMRPA’s recommendations pertaining to the Quality Payment Program: In order to make the Merit-based Incentive Payment System (MIPS) a comprehensive and effective value-based payment system, and to avoid creating an unreasonable financial disadvantage for facility-based therapy providers, CMS should work with stakeholders to allow for facility-based outpatient therapy providers to be included in MIPS in the least burdensome manner possible. For those therapists that CMS does propose to include in MIPS in 2019, their inclusion in the program with just two months’ notice is overly burdensome and would ultimately prove counterproductive. AMRPA urges CMS to provide at least one year of notice and education before incorporating new clinicians into MIPS in a mandatory fashion and to also provide flexible scoring policies in the first year of participation.

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AMRPA encourages CMS to expedite its work to develop a MIPS facility-based scoring option that allows IRH/U and other post-acute care providers to substitute a facility score for MIPS in the same manner that is being offered for acutecare hospital providers. AMRPA urges CMS to closely monitor the formation of virtual groups under MIPS and the scores of these virtual groups relative to non-virtual group scores. CMS should also produce a report detailing how virtual group reporting enhances the value of patient care in the same manner that real group reporting does. Ultimately, AMRPA urges CMS to reconsider its virtual group policies in light of the policies’ lack of grounding in real-world medical practice. The following is a summary of AMRPA’s recommendations pertaining to the Physician Fee Schedule: AMRPA strongly recommends that CMS not proceed with its proposal to consolidate payment rates for Evaluation and Management (E/M) visit levels due to the risk to patients coupled with the nominal burden reduction offered in exchange for this payment reduction. AMRPA recommends that CMS not make similar changes to E/M codes for the inpatient sites of care and instead focus its attention on lessening the burden associated with the extensive IRH/U regulations. Reducing redundancy and unnecessary documentation needed to comply with these hospital regulations would be the best way to reduce physician burden in the inpatient setting. AMRPA opposes CMS’ proposed definition of therapy services provided “in-part” by a therapy assistant and urges CMS to finalize a more lenient definition. AMRPA also encourages CMS to conduct a full-scale analysis of the current utilization of therapy assistants and how a payment reduction for use of assistants will effect Medicare beneficiaries’ access to necessary rehabilitation therapy services.

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AMRPA encourages CMS to finalize its proposal to remove the functional reporting requirements for outpatient therapy services. In addition, AMRPA urges CMS to continue to study and evaluate how functional outcomes can be properly accounted for in the delivery of therapy services via other methods. For example, AMRPA encourages CMS to explore incorporating functional outcomes as a measure under the MIPS program, and to similarly account for functional outcomes in any other alternative payment models it develops. The following is a summary of AMRPA’s recommendations pertaining to the Medicare Shared Savings Program (MSSP), which are more fully articulated in section X. of this letter: CMS must risk adjust the functional status data used in evaluating Accountable Care Organizations (ACOs) to ensure that the data reflects the true picture of an ACO’s beneficiary pool. In order to track ACO beneficiaries’ functional changes over time, CMS must collect functional status data from multiple points in time. AMRPA encourages CMS to work with the medical rehabilitation community and leverage the field’s broad experience with measuring function to develop appropriate quality measures for application in the MSSP. AMRPA supports removing the Skilled Nursing Facility (SNF) 30-Day All-Cause Readmission Measure from the MSSP ACO quality measure set. In its place, AMRPA supports adding the Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNFs.

NIDILRR Issues 2017 Disability Statistics Annual Report

The Rehabilitation Research and Training Center on Disability Statistics and Demographics of the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) Center recently published the 2017 Disability Statistics Annual Report, which presents statistics on persons with disabilities, age groups, types of disabilities, employment, earnings, etc. The 2018 report is expected to be published in February 2019. The American Community Survey (ACS) provides estimates of persons with the highest percentage of disabilities in all states. The percent of people with disabilities varied greatly by state, as well as the levels of persons with disabilities in employment, poverty, earnings, and health behaviors. This article provides findings from the report. Persons with Disabilities The overall percentage of persons with disabilities in the US population in 2016 was 12.8 percent, a slow increase from 11.9 percent in 2010. In 2016, the state with the lowest percentage of its population having a disability was Utah (9.9 percent). The state with the highest percentage of disability, West Virginia, was more than twice as high with a percentage of 20.1 percent.

Figure 1. Percentage of people in the U.S. with disabilities, 2008-2016

Figure 2. People with disabilities living in the community as a percentage of the U.S. population, by state, 2016

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Age Groups In 2016, less than 1.0 percent of the under 5 years-old population had a disability. For those ages 5-17, the rate was 5.6 percent. For ages 18-64, the rate was 10.6 percent. For people ages 65 and older, 35.2 percent had a disability. (Figure 3).

Figure 9. People with disabilities, by type and year, 2008-2016

Figure 3. Age distribution of disability in the U.S. population, 2016

Employment

Of the U.S. population in 2016 with disabilities, more than half (51.0 percent) were working age, 18- 64, while 41.4 percent were 65 and older. Disability in children and youth accounted for only 7.3 percent (ages 5-17) and 0.4 percent (under 5 years old). (Figure 4)

In 2016, 35.9 percent of people with disabilities aged 18-64 living in the community were employed. The employment percentage was more than double for people without disabilities, 76.6 percent. The employment gap, the difference between the employment percentage for people with disabilities (35.9 percent) and people without disabilities (76.6 percent), was 40.7 percentage points. (Figure 16).

Figure 16. Employment percentage, with and without disability, 2—8-2016

Figure 4. Age distribution in the U.S. population of people with disabilities, ACS, 2016

Types of Disabilities From 2008 to 2016, the percentage of people with each type of disability remained relatively unchanged. The percentage of people with ambulatory disabilities, cognitive disabilities and independent living disabilities rose by 0.2 to 0.3 points over the period, while people with hearing, vision, and selfcare disabilities rose 0.1 point or less. (Figure 9).

For more statistics, see the complete report, 2017 Disability Statistics Annual Report.

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Employment rates varied by type of disability. Employment percentages were highest for people with hearing disabilities (51.7 percent) and vision disabilities (43.5 percent) and lowest for independent living (17.0 percent) and self-care (15.5 percent) disabilities. (Figure 21).

Figure 21. Employment percentage by type of disability, ages 18-64, 2016

Visual Training and Rehabilitation in Restoring Partial Blindness

Roughly one-third of patients who have suffered a stroke suffer from hemianopia, or diminished vision or blindness in half of the visual field. Hemianopia can onset as a consequence of stroke or trauma to the brain, and greatly impacts a patient’s quality of life. Although hemianopia was long considered irreversible, recent studies show that vision training through rehabilitation after optic nerve and brain damage can help restore or improve vision. A recent study published in the journal Clinical Neurophysiology found that visual training and rehabilitation can significantly improve visual function by helping activate the brain’s attentional networks. Specifically, neuroimaging tests showed that visual training was associated with a strengthening of the brain’s cortical attentional network connections and demonstrated that these networks are key mechanisms in partially reversing blindness.

// A recent study published in the journal Clinical Neurophysiology found that visual training and rehabilitation can significantly improve visual function by helping activate the brain’s attentional networks.

Seven chronic hemianopic patients with lesions of the visual cortex took part in vision rehabilitation training for five weeks. After pre-tests, all received training sessions six days per week for five weeks. Each training session, lasting about 60 minutes, was composed of six blocks with 120 training trials each, during which participants had to respond to specially designed visual stimuli on a computer monitor. The preand post-test included perimetry testing, contrast sensitivity testing and functional magnetic resonance imaging (fMRI) scanning one or two days before and after training, respectively. Each contrast sensitivity test consisted of 420 trials in six blocks. The visual rehabilitation training was performed with one eye open, which was randomly chosen, while the non-trained eye was covered with an opaque eye patch. After training, the patients had significantly improved visual function at the training location, and fMRI showed that the training led to a strengthening of the cortical attentional network connections between the brain region of the right temporoparietal junction (rTPJ) and the insula and the anterior cingulate cortex (ACC).

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“Knowledge in this field is still rather fragmentary, but recent studies have shown that vision can be partially restored by vision training, which improves the deficient visual field sectors,” explained Bernhard Sabel, PhD, Director of the Institute of Medical Psychology at Magdeburg University, Germany, coinvestigator of the study. The study confirmed this hypothesis by obtaining fMIR evidence that visual training led to functional connectivity reorganization of the brain´s attentional network. The authors note that it is unclear

whether the reorganization of attentional networks is the direct result of visual training versus other sensory factors, and suggest this be investigated in future studies. For the complete study, see “Visual rehabilitation training alters attentional networks in hemianopia: An fMRI study,” by Qilin Lu, Xiaoxiao Wang, Lin Li, Bensheng Qiu, Shihui Wei, Bernhard A. Sabel, Yifeng Zhou, Clinical Neurophysiology 129:9 (2018). https://doi.org/10.1016/j.clinph.2018.05.027

Let’s Stay in Touch

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

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

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

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

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

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

Analyzing Quality of Life and Function in Traumatic Spinal Cord Injury Patients Highlights: »»

The study found differences in important functional abilities for TSCI patients with tetraplegia versus paraplegia.

Independence in mobility is the single most important factor affecting quality of life in patients with traumatic spinal cord injury (TSCI), according to a study in the American Journal of Physical Medicine and Rehabilitation. Using validated clinical questionnaires, the study is the first objective evaluation of the relative importance of specific functional abilities following TSCI. The study included 195 patients with TSCI admitted to a specialized trauma center between 2010 and 2016. Most patients were injured in falls or motor vehicle accidents; about 65 percent were tetraplegic (or “quadriplegic”), with paralysis of both the upper and lower limbs; and 35 percent were paraplegic, with paralysis of the lower limbs only.

// Quality of life (QoL) has become a major focus of outcome evaluation for patients with spinal cord injury and other chronic conditions.

Quality of life (QoL) has become a major focus of outcome evaluation for patients with spinal cord injury and other chronic conditions. Six to 12 months after injury, the patients completed a standard questionnaire, Spinal Cord Independence Measure (SCIM), to evaluate the level of independence in 19 functional abilities related to activities of daily living (ADLs). Another questionnaire (Short Form Health Survey, SF-36) was used to assess health-related quality of life, including physical and mental components. Associations between these widely used questionnaires were analyzed to determine which areas of functional ability had the greatest impact on QoL after TSCI. As seen in previous studies, total scores on the SCIM and QoL assessments were significantly correlated with each other. The study revealed some differences in the most important functional abilities for TSCI patients with tetraplegia versus paraplegia. Overall, factors on the mobility subscale of the SCIM had the largest effect on the physical component of QoL, followed by factors on the self-care and respiration/sphincter management subscales. This trend was strongest among tetraplegic patients.

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In contrast, for paraplegic patients, mobility was the only SCIM subscale that significantly correlated with the physical QoL score. This result was consistent with previous studies reporting the high priority for walking among TSCI patients with paraplegia. In both groups, indoor and outdoor mobility was more important for physical QoL, compared to other measures of mobility (such as managing stairs or transferring from bed to wheelchair). The greater importance of self-care abilities in TSCI patients with tetraplegia reflected the importance of arm and hand function for daily activities such as bathing, dressing and grooming. While earlier studies have examined the difference in functional abilities following after spinal cord injury, this study took a novel approach in using clinical outcomes questionnaires to assess the

factors most important to QoL for TSCI patients with injury to different spinal cord levels. "Our study showed that it is of paramount importance to analyze tetraplegic and paraplegic patients distinctly when evaluating the impact of function on QoL," the authors wrote. "Different priorities for patients lead to distinct goals in the rehabilitation effort." For the study, see "Relationships between Specific Functional Abilities and Health-Related Quality of Life in Chronic Traumatic Spinal Cord Injury" American Journal of Physical Medicine & Rehabilitation: August 28, 2018.

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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 of Membership Services · 347-573-3732 · mramirez@amrpa.org Samantha Schwarz,· AMRPA Member Services Coordinator, 202-207-1132, sschwarz@amrpa.org

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Study Assesses the Association of Medicaid Expansion, Access to Rehabilitation and Unplanned Readmissions among Hospitalized Young Adult Trauma Patients Highlights: ÂťÂť

The study did not find significant reductions in in-hospital mortality or unplanned readmissions between pre- or post-Medicaid expansion for young adults hospitalized for traumatic injury.

A recent study published in JAMA Surgery examined whether the first year of Medicaid expansion through the Affordable Care Act (ACA) was associated with changes in insurance coverage and improved outcomes in young adults hospitalized for traumatic injury. Trauma is the leading cause of death and disability among young adults in the United States, and young adults are also the age group most likely to be uninsured. Although Medicaid expansion has increased insurance coverage across age groups, its associations with trauma care and outcomes among young adults nationwide remains unknown. Pursuant to the ACA, Medicaid expansion plans must cover a specific set of essential health benefits, which include rehabilitative and habilitative services.

// Trauma is the leading cause of death and disability among young adults in the United States, and young adults are also the age group most likely to be uninsured.

The authors assessed the associations of ACA Medicaid expansion with insurance coverage, in-hospital mortality, failure to rescue, discharge to rehabilitation (inpatient rehabilitation hospital or unit, skilled nursing facility, or home health agency), and unplanned readmissions among hospitalized young adult trauma patients across the U.S. The Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases were used to examine changes in insurance coverage and risk-adjusted outcomes among young adults (age 19 to 44 years) who were hospitalized for injuries before and after Medicaid

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expansion and open enrollment occurred (2012-2013 versus 2014) in 11 states that expanded Medicaid through the ACA. The study authors also performed difference-in-difference analyses to compare these changes between three expansion states and three non-expansion states within the same geographic region. Results Of the 141,187 trauma patients hospitalized across 11 Medicaid expansion states, 43,871 (31.1 percent) were women, and the mean (SD) age was 31.4 (7.6) years. Medicaid expansion was associated with an increase in Medicaid coverage from 16.7 percent in 2012-2013 to 34.9 percent in 2014 (difference: 18.2 percent [95 percent CI, 16.5 percent-20.0 percent]; P < .001), a decrease in lack of insurance from 27.8 percent to 12.7 percent (difference: −15.1 percent [95 percent CI, −16.8 percent to −13.5 percent]; P < .001), and an increase in discharge to rehabilitation from 11.4 percent to 12.6 percent (difference: 1.16 percent [95 percent CI, 0.55 percent-1.77 percent]; P < .001).

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Findings The study found that the first year of implementation of Medicaid expansion and open enrollment across 11 selected US states was associated with significant increases in Medicaid coverage (18.2 percent), reductions in uninsured rates (-15.1 percent), and increased access to post-discharge rehabilitation among young adults hospitalized for injury (1.2 percent). The study did not find significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions between pre- or post-Medicaid expansion for this clinical patient cohort. For the abstract, see, “Association of Medicaid Expansion Under the Affordable Care Act With Outcomes and Access to Rehabilitation in Young Adult Trauma Patients”. August 15, 2018. JAMA Surg. 2018;153(8):e181630. doi:10.1001/ jamasurg.2018.1630

Presence of Pressure Ulcers Associated with Poorer Functional Outcomes in Inpatient Rehabilitation Patients Highlights: »»

Pressure ulcer quality indicator was associated with poorer rehabilitation outcomes.

According to a recent study in the Archives of Physical Medicine and Rehabilitation, the presence of new or worsened pressure ulcers is an effective indicator of the quality of care for inpatient rehabilitation patients. New or worsened pressure ulcers is a quality metric instituted as part of the Affordable Care Act (ACA) and requires that medical institutions be evaluated on their quality of care. Since 2012, inpatient rehabilitation providers have reported a quality measure on new or worsened pressure ulcers post-admission to the Centers of Medicare and Medicaid Services’ (CMS) as mandated by the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP).

// According to the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ), pressure ulcers, also known as bedsores, cost the U.S. health care system between $9.1 billion and $11.6 billion per year.

According to the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ), pressure ulcers, also known as bedsores, cost the U.S. health care system between $9.1 billion and $11.6 billion per year. Previous studies have shown an association between the presence of bedsores and a variety of outcomes for patients in acute care hospitals and long-term care facilities. However, the association between pressure injury development and rehabilitation-related outcomes, such as function and discharge destination, among inpatient rehabilitation patients had not been examined previously. To assess the association between the pressure ulcer quality indicator and IRF patient outcomes, the study examined patients who did or did not develop pressure ulcers during their inpatient rehabilitation stay and the following outcomes: functional independence (as measured by the Functional Independence Measure [FIM™]), functional change (gain) and discharge destination. Study participants included

AMRPA Magazine / October 2018 33

approximately 500,000 IRF Medicare patients who were discharged between January 2013 and September 2014. Results The researchers found that pressure ulcer quality indicator was associated with poorer rehabilitation outcomes; patients who developed new or worsened pressure ulcers were less likely to achieve functional independence (odds ratio [OR], .47; 95 percent confidence interval [CI], .44–.51), were less likely to be discharged to a community setting (OR, .88; 95 percent CI, .82–.95), and made less functional gain during their IRF stay (a difference of 6 FIM points). While outcomes were poorer for those with new or worsened pressure ulcers, more than half of these patients were able to be discharged to a community setting.

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Compared to the control group, patients with a new or worsened pressure ulcers tended to have a lower change score on the FIM™ and have, on average, a longer rehabilitation stay. In this study, about 1 percent of patients experienced new or worsened bedsores during their rehabilitation stay. According to the researchers, the study demonstrated that Medicare’s pressure ulcer indicator was associated with poorer outcomes for inpatient rehabilitation patients, and hence could serve as a proxy measure of IRF quality. For the report, see “Mandated Quality of Care Metrics for Medicare Patients: Examining New or Worsened Pressure Ulcers and Rehabilitation Outcomes in United States Inpatient Rehabilitation Facilities” Archives of Physical Medicine and Rehabilitation, August 2018, Volume 99, Issue 8, Pages 1514– 1524.e1

Study Finds Differences in Outcomes for BPCI Model 2 Cardiac Bundles Participants and Non-Participants

Highlights: »»

Hospitals participating in BPCI model 2 cardiac bundles had higher AMI and CHF discharge volumes and lower mortality rates than nonparticipating hospitals.

Medicare’s Bundled Payments for Care Improvement (BPCI) Initiative is a voluntary program to test the impact of bundled payments on the costs and outcomes of certain clinical conditions, including several common cardiovascular conditions. A recent study in JAMA Cardiology evaluated the external validity of the BPCI program and the effects of bundled payments on cardiac care. Furthermore, the study authors sought to determine if hospitals participating in BPCI for cardiac bundles differed from nonparticipating hospitals in ways that could limit program outcomes to all acute care hospitals, and to identify factors associated with participation.

// A recent study in JAMA Cardiology evaluated the external validity of the BPCI program and the effects of bundled payments on cardiac care.

The study design was a retrospective cross-sectional study of hospitals participating in BPCI model 2 bundles for acute myocardial infarction (AMI), congestive heart failure (CHF), coronary artery bypass graft, and percutaneous coronary intervention, and nonparticipating control hospitals (October 2013 to January 2017). The BPCI model 2 episode bundles the acute care, or “trigger,” hospitalization and the following 30, 60 or 90 days of post-acute care. BPCI participant hospitals were identified using data from the Centers for Medicare and Medicaid Services (CMS), and controls were identified using the 2013 American Hospital Association’s Survey of US Hospitals. Hospital structural characteristics and clinical performance data were obtained from the American Heart Association survey and CMS. One hundred fifty-nine hospitals participating in BPCI model 2 cardiac bundles and 1,240 nonparticipating control hospitals were compared, and a multivariable logistic regression was estimated to identify predictors of BPCI participation.

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The main outcomes and measures were hospital-level structural characteristics and 30-day risk-adjusted readmission and mortality rates for AMI and CHF.

with participation. Being a safety net hospital was negatively associated with participation (odds ratio, 0.3; 95 percent CI, 0.10.7; P = .001).

The study found that compared with nonparticipants, BPCI participants were larger, more likely to be privately owned or teaching hospitals, had lower Medicaid bed day ratios (ratio of Medicaid inpatient days to total inpatient days: 17.0 vs 19.3; P < .001), and were less likely to be safety net hospitals (2.5 percent vs 12.3 percent; P < .001). BPCI participants had higher AMI and CHF discharge volumes, were more likely to have cardiac intensive care units and catheterization laboratories, and had lower risk-standardized 30-day mortality rates for AMI (13.7 percent vs 16.6 percent; P = .001) and CHF (11.3 vs 12.4; P = .005). In multivariable analysis, larger hospital size and access to a cardiac catheterization laboratory were positively associated

The authors concluded that hospitals participating in BPCI model 2 cardiac bundles differed in significant ways from nonparticipating hospitals. The BPCI outcomes may therefore have limited external validity, particularly among small and safety net hospitals with limited clinical cardiac services.

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For the abstract, see Factors Associated With Participation in Cardiac Episode Payments Included in Medicare’s Bundled Payments for Care Improvement Initiative, Brief Report, August 2018, JAMA Cardiology 2018;3(8):761-766. doi:10.1001/ jamacardio.2018.1736.

Hospital Participation in the BPCI Was Not Associated with Significant Changes in Volume or Most Patient CaseMix Factors Highlights: »»

Hospital BPCI participation was not associated with changes in market-level lower extremity joint replacement volume.

Although Medicare’s Bundled Payments for Care Improvement (BPCI) Initiative has been associated with a reduction in episode spending and stable-toimproved quality for lower extremity joint replacement (LEJR) surgery, policymakers and researchers also have concerns that the program may create unintended effects. These include incentivizing participating hospitals to increase the overall volume of episodes paid for by Medicare, which could potentially eliminate program-related savings, or prompting hospitals to shift case mix to lower-risk patients.

// A recent study in JAMA sought to evaluate whether a hospital’s BPCI participation was associated with changes in overall volume and case mix for LEJR procedures.

A recent study in JAMA sought to evaluate whether a hospital’s BPCI participation was associated with changes in overall volume and case mix for LEJR procedures. In short, they did not find significant associations between BPCI program participation and changes in volume or most patient case-mix factors. According to the study authors, this may provide reassurance about two potential unintended effects of voluntary bundled payments for lower extremity joint replacement. The study participants included 1,717,243 Medicare beneficiaries who underwent LEJR, (mean age, 75 years; 64 percent women; and 95 percent nonblack race/ethnicity). The observational study used Medicare claims data and a difference-in-differences method to compare 131 markets (hospital referral regions) with at least 1 BPCI participant hospital (n = 322) and 175 markets with no participating hospitals (n = 1340), accounting for 580,043 Medicare beneficiaries treated before (January 2011-September 2013) and 462,161 after (October 2013-December 2015) establishing the BPCI initiative. Hospitallevel case-mix changes were assessed by comparing 265 participating hospitals with a 1:1 propensity-matched set of nonparticipating hospitals from non-BPCI markets.

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The main outcomes and measures were changes in marketlevel LEJR volume in the before- versus after-BPCI periods, and changes in hospital-level case mix based on demographic, socioeconomic, clinical, and utilization factors.

with differential changes in hospital-level case mix for only one factor, prior skilled nursing facility use (adjusted difference-indifferences estimate, −0.53 percent; 95 percent CI, −0.96 percent to −0.10 percent; P = .01) in BPCI vs non-BPCI markets.

Results Among the 1,717,243 Medicare beneficiaries who underwent LEJR, BPCI participation was not significantly associated with a change in overall market-level volume. The mean quarterly market volume in non-BPCI markets increased 3.8 percent from 3.8 episodes per 1,000 beneficiaries before BPCI to 3.9 episodes per 1000 beneficiaries after BPCI was launched. For BPCI markets, the mean quarterly market volume increased 4.4 percent from 3.6 episodes per 1000 beneficiaries before BPCI to 3.8 episodes per 1,000 beneficiaries after BPCI was launched. The adjusted difference-in-differences estimate between the market types was 0.32 percent (95 percent CI, −0.06 percent to 0.69 percent; P = .10). Among 20 demographic, socioeconomic, clinical, and utilization factors, BPCI participation was associated

For the Medicare beneficiaries who underwent LEJR, hospital participation in the BPCI was not associated with changes in market-level LEJR volume (adjusted difference-in-differences estimate, 0.32 percent) and largely was not associated with changes in hospital case mix, with only one of 20 case-mix characteristics associated with a lower likelihood of undergoing LEJR at a BPCI-participating hospital.

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For the abstract see “Association of Hospital Participation in a Medicare Bundled Payment Program With Volume and Case Mix of Lower Extremity Joint Replacement Episodes, September 4, 2018, JAMA. 2018;320(9):901-910. doi:10.1001/jama.2018.12345

Latest Research Findings

Stroke Patients Twice As Likely To Develop Dementia New research published in the journal Alzheimer's & Dementia has found that people who have had a stroke were twice as likely to develop dementia. According to the World Health Organization (WHO), 15 million persons have a stroke each year and around 50 million people globally have dementia – a number expected to almost double over 20 years, reaching 131 million by 2050. The University of Exeter Medical School conducted a metaanalysis of the relationship between stroke and all-cause dementia with over three million study participants. The study builds on previous research that had established the link between stroke and dementia, though had not quantified the degree to which stroke actually increased dementia risk. To better understand the link between the two, researchers analyzed 36 studies where

participants had a history of stroke, totaling data from 1.9 million people. In addition, they analyzed 12 other studies that examined whether participants had a recent stroke over the study period, adding an additional 1.3 million persons. The researchers found strong evidence to support a significantly increased risk of all-cause dementia in persons with a history of stroke. The link between stroke and dementia persisted even after taking into account other dementia risk factors such as blood pressure, diabetes and cardiovascular disease. Stroke characteristics such as the location and extent of brain damage may help to explain variation in dementia risk observed between studies, and there was some suggestion that dementia risk may be higher for men following stroke. The study states that further research is required to clarify whether factors such as ethnicity and education modify dementia risk following stroke. Because most people who have a stroke do not go on to develop dementia, the authors note that further research is also needed to establish whether differences in post-stroke care and lifestyle can reduce the further risk of dementia. Dr. David Llewellyn, from the University of Exeter Medical School, concluded, “Around a third of dementia cases are thought to be potentially preventable, though this estimate does not take into account the risk associated with stroke. The study findings indicate that this figure could be even higher, and reinforce the importance of protecting the blood supply to the brain when attempting to reduce the global burden of dementia.” The full paper, ‘Stroke and dementia risk: A systematic review and meta-analysis’, was published in Alzheimer’s and Dementia: The Journal of the Alzheimer's Association, August 31, 2018.

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Study Finds Significant Declines in Observed Bladder Catheterization and CAUTI Frequency The Centers of Medicare and Medicaid Services (CMS) implemented the public reporting of hospital-acquired infections in 2011, but there is limited research on whether infection rates, such as bladder catheterization and catheter-associated urinary tract infection (CAUTI), have improved as a result. A recent study found that there were statistically significant declines in observed bladder catheterization frequency and adjusted CAUTI frequency in some patient populations between 2009 and 2014. A study published in the American Journal of Infection Control analyzed data from the Medicare Patient Safety Monitoring System, a national, chart abstraction-based surveillance system, for hospitalized adults with a principal discharge diagnosis of heart failure (HF), acute myocardial infarction (AMI) or pneumonia and patients who had undergone certain major surgeries. The authors assessed bladder catheterization frequency (percentage of patients catheterized) and risk-adjusted CAUTI frequency (percentage of catheterized patients developing CAUTI) from 2009-2014. The study found that bladder catheterization frequency declined significantly (6.6 percent for AMI patients, 8.0 percent for HF patients, and 5.7 percent for surgical patients). For pneumonia patients, there was a non-significant increase of 1.1 percent. The risk-adjusted CAUTI rate among AMI patients decreased by 9.7 percent each year relative to the year before. For

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surgical patients, the decrease was 9.1 percent per year. There was no significant decline among HF or pneumonia patients. The overall burden of CAUTI among surgical patients was higher than for the other conditions because surgical patients were more likely to be catheterized. For the abstract â&#x20AC;&#x153;National trends in the frequency of bladder catheterization and physician-diagnosed catheter-associated urinary tract infections: Results from the Medicare Patient Safety Monitoring System,â&#x20AC;? see American Journal of Infection Control, 2017 Aug 1;45(8):901-904. doi: 10.1016/j.ajic.2017.03.008. Epub 2017 Jun 16

Primary elections have come to an end, but congressional candidates are gearing up for an intense mid-term election season and are keenly aware of the importance of visiting with and listening to the concerns of their constituents. AMRPA encourages its members to use the coming weeks to educate candidates running for congressional office about the value of care provided in inpatient rehabilitation hospitals and units by offering them a tour of your hospital, meeting with them at their offices, or visiting with them during town hall or community meetings.

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

We greatly appreciate your time and willingness to help AMRPA communicate the importance of access and protection for patients that need medically necessary rehabilitative care.

In preparation for meeting with the candidates, here’s an AMRPA excerpt discussing the value of inpatient medical rehabilitation:

Scheduling a Meeting with the Candidates Seeking Election Use the links below to locate their campaign headquarters and contact information. Call, email, or submit an online contact form requesting a meeting with the candidate or extending an invitation to your hospital or unit. House candidates: https://www.realclearpolitics.com/ epolls/2018/house/2018_elections_house_map.html Senate candidates: https://www.realclearpolitics.com/ epolls/2018/senate/2018_elections_senate_map.html If one of the candidates is an incumbent member of Congress running for reelection, you may also follow these steps to set up a meeting: Call the U.S. Capitol Switchboard at (202) 224-3121 and ask for your senators’ and representative's office or access their contact information online at www.house. gov and www.senate.gov. Ask the office for instructions regarding the preferred way to submit a request for a meeting or an invitation to tour your hospital or unit in the district/state. Congressional offices handle their district scheduling requests differently. The Washington, DC, office may arrange for the meeting directly or may refer you to their congressional district office to set up the visit.

Find your House Representative here: www.house.gov/ representatives/find-your-representative Find your Senators here: www.senate.gov/general/ contact_information/senators_cfm.cfm Once you have a meeting or tour scheduled, inform Kendall Hussey (khussey@akingump.com, (202) 416-5207) so we can track AMRPA’s outreach efforts.

Inpatient Rehabilitation Hospitals and Units Provide Critically Important Care to People Overcoming Challenges from Injuries, Illnesses, and Conditions What is Inpatient Medical Rehabilitation? Inpatient medical rehabilitation is a critical component of the health care delivery system. Medical rehabilitation refers to evaluation, diagnosis, treatment, and procedures that seek to minimize physical and cognitive impairments, prevent institutionalization and re-hospitalization, and optimize functional ability, thereby reducing the impact of a disabling condition on the quality and productivity of a patient’s life.1 The goals and purpose of inpatient medical rehabilitation have been described in various ways with the primary emphasis on restoring a person’s ability to function in a normal manner. Medical rehabilitation may begin during a patient’s stay in an acute care hospital in order to help the

There are varying definitions of rehabilitation. The World Health Organization describes rehabilitation as “instrumental in enabling people with limitations in functioning to remain in or return to their home or community, live independently, and participate in education, the labour market and civic life.” See http://www.who.int/disabilities/care/en/. The National Association of Insurance Commissioners defines rehabilitation as “health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.” The Department of Health and Human Services mandates that all state health exchange insurance plans include within their essential health benefits rehabilitative and habilitative services. HHS defines rehabilitative and habilitative services as “services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.” See https://www.healthcare.gov/blog/10health-care-benefits-covered-in-the-health-insurance-marketplace/.

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patient move, walk, talk, dress, and/or eat independently without assistance. Medical rehabilitation prevents unnecessary medical costs in the long-term and allows patients to return to the most important people and activities in their lives. For the majority of clinicians and advocates in the medical rehabilitation field, the preferred term for patients is “persons with disabling conditions” (PWD). The emphasis is placed on an individual patient’s ability to function and not on his/her disabling condition. Conditions Necessitating Inpatient Medical Rehabilitation Unlike acute care hospitals, which focus on a patient’s diagnosis in developing a care plan, inpatient rehabilitation hospitals and units (IRH/Us) consider an individual’s function, other patient characteristics, and environmental factors in determining the appropriate care for a patient. Conditions commonly treated in medical rehabilitation hospitals include stroke, brain and spinal cord injuries, neurological diseases, major musculoskeletal disorders, cardiopulmonary disorders, and transplantation. IRH/Us are also referred to as inpatient rehabilitation facilities or “IRFs” by the Centers for Medicare and Medicaid Services (CMS). Characteristics of a Rehabilitation Patient Patients treated in inpatient rehabilitation hospitals and rehabilitation units of acute care hospitals are among the most vulnerable in American society. Almost all patients admitted to IRH/Us have recent adverse events such as hospitalization, sudden injury, illness, trauma, or pain. The Mission of Inpatient Rehabilitation Hospitals/ Units IRH/Us provide rehabilitation to patients working to overcome some of the most challenging injuries and conditions. IRH/Us work daily with beneficiaries of Medicare, Medicaid, and private insurance to maximize their health, functional skills, independence, and participation in society so they are able to return to home, work, or an active retirement. Development of the Medical Rehabilitation Field The medical rehabilitation field was developed early in the 20th century by visionaries who believed that there was more to health care than simply diagnosing and medically treating patients with serious permanent impairments. They believed that such patients could, with appropriate rehabilitation, return to active and productive lives and contribute to their family, community, and the economic life of the nation. Over the years, the work of physician-directed, hospital-based interdisciplinary teams comprised of rehabilitation physicians and nurses, as well as physical, occupational, and speech language therapists, who are devoted to the principles of rehabilitation evolved into the field of medical rehabilitation as we know it today.

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In reaction to the implementation of the Inpatient Prospective Payment System (IPPS) in 1983, many acute care hospitals responded to various incentives therein by discharging patients more quickly and with greater medical complexity, frequently referred to as “sooner or sicker.” Due to the growing volume of patients who needed care subsequent to their acute care stay, the number of rehabilitation providers began to grow in order to treat the number of patients needing medical rehabilitation services. The predecessor organization to the American Medical Rehabilitation Providers Association (AMRPA) completed a survey of IRH/Us in 1984 and found there were 308 rehabilitation units and 49 rehabilitation hospitals. In 2018, there are 896 rehabilitation units and 282 rehabilitation hospitals. Inpatient Rehabilitation Hospital/Unit Payers Approximately 60 percent of IRH/U patient care is compensated through Medicare Part A under the traditional Medicare fee-for-service payment (FFS) model referred to as the Medicare Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). IRH/ Us additionally treat patients whose care is paid for by Medicaid or commercial insurers. A growing number of IRH/Us receive payment through Medicare managed care plans. Several IRH/Us participate in alternative payment models such as the Bundled Payments for Care Improvement (BPCI) initiative and accountable care organizations (ACOs). Since implementation of the IRF PPS in 2002, IRH/Us have been required to complete the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI). The IRF-PAI is an assessment tool that collects highly detailed information about a patient’s diagnosis, comorbidities and complexities, length of stay, motor and cognitive functioning, as well as discharge destination and initial referring site. The IRF-PAI provides additional patient data that would be helpful in characterizing and understanding patient outcomes and burden of care, IRH/ Us’ readmissions patterns, patient characteristics, and developing risk adjustment analyses. IRH/Us report their patient data to CMS.

For more voting information, and to find out if you are registered, please visit: www.usa.gov/voting. We encourage members to also check the Congressional Elections webpage for more up-to-date information: http://amrpa.org/Advocacy/2018-CongressionalElections. If you have any questions or feedback, please contact Catherine Beal at cbeal@amrpa.org or (202) 860-1006.

The First Rule of Engagement Is to Actually Engage Patient engagement drives recovery and improved outcomes. Kindred’s RehabTracker app drives patient engagement. RehabTracker’s technology allows therapy teams to put the patient at the center of their recovery. With real-time tracking of goals and the ability to share progress with their loved ones, patients are motivated and engaged to reach their full potential. Therapy teams can be more efficient with the ability to input functional measure scores with the patient, track ambulation improvement, highlight their patient progress and more.

To learn more about RehabTracker and why KHRS is the partner of choice for hospital systems across the country, visit kindredrehab.com.

Clinical Quality and Effectiveness

Physician Engagement

Patient Throughput Management

Regulatory Compliance AMRPA Magazine / October 2018 43

AMRPA & eRehabDataÂŽ Have Your Back

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

Visit eRehabData.com to learn more, or contact Sam Fleming at sam@erehabdata.com to receive a free demo. Without losing any historical data, our staff help you migrate to the only patient assessment system that is trusted, owned, used, and supported by the medical rehabilitation industry. 44 AMRPA Magazine / October 2018