AMRPA Magazine - July 2019

July 2019 • Vol. 22, No.7

2019

2019 FALL

Fall Educational Conference Loews Coronado Bay Resort & Expo San Diego, CA | October 14-16, 2019

EDUCATIONAL CONFERENCE & EXPO Loews Coronado Bay Resort San Diego, CA October 14-16, 2019

AMRPA National Leadership Excellence Award AMRPA is now accepting nominations for our annual National Leadership Excellence Award, to be presented at this year’s Fall Educational Conference & Expo in San Diego.

The AMRPA National Leadership Excellence Award is an opportunity to offer recognition to individuals who have exemplified outstanding service and made significant contributions to the field of medical rehabilitation. These accomplishments should contribute to the advancement of the medical rehabilitation field as a whole, as opposed to benefiting only an individual’s institution.

Who Qualifies?

Nominated persons should exemplify leadership, integrity, vision, dedication, and excellence in at least three of the following areas:     

Transformative Leadership Professional Experience Life-long Service in the Field Advocacy at the State and National Level Mentorship of Future Leaders

 Improved Patient Outcomes/ Quality of Patient Care  Research and Critical Analysis  Education and Advancement of the Field

Nominating parties will be asked to provide examples illustrating such excellence in these categories.

Click here for more information.

How Do I Nominate Someone?

To nominate a colleague, visit the AMRPA website and complete the Nomination Form. The AMRPA Awards Committee will review all submissions and notify the nominator once the selection is made.

Click here to nominate a colleague!

#AMRPA

Questions about nominations?

Contact Julia Scott, AMRPA Member Services Coordinator, at jscott@amrpa.org for assistance.

July 2019 • Vol. 22, No. 7

The official publication of the American Medical Rehabilitation Providers Association (AMRPA) Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Director Kate Beller, JD AMRPA Executive Vice President for Government Relations and Policy Development Carolyn Zollar, MA, JD AMRPA Senior Policy Counsel Mimi Zhang AMRPA Director of Payment Innovation, Quality and Research Patricia Sullivan AMRPA Senior Editor Brian McGowan Design and Layout

Table of Contents Letter from the Chair

4

Legislative Update

6

CMS Offers Groundbreaking Settlement to Inpatient Rehabilitation Hospitals and Units

8

Modifications to the CMGs in the Proposed Rule

10

AMRPA Highlights the Importance of Robust Data in Assessing the Proposed FY 2020 Case Mix Policy

13

A Look at Health System Participation in ACOs and Bundled Payment Models, 2016

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AMRPA Submits Comments on CMS and ONC Proposed Rules Regarding Interoperability

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Musculoskeletal Disease Second-highest Global Cause of Years Lived with Disability

29

Family Involvement in Inpatient Rehabilitation for Traumatic Brain Injury Patients

30

OIG Examines Heath IT Use and Care Coordination in Medicare ACOs

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HHS Issues Final Report on Pain Management Best Practices

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AMRPA Magazine, Volume 22, Number 7

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

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

SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues.

Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color.

Contact Brian McGowan, bmcgowan@kellencompany.com for additional specs and acceptable submission format.

Advertising Contact: Julia Scott, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1110, Email: jscott@amrpa.org.

Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content Š2019

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 / July 2019

3

Letter from the Chair

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

Countering Efforts to Impose Prior Authorization Prior authorization for inpatient rehabilitation services is a critical issue to AMRPA. Recall that the 2018 report by the Department of Health and Human Services Office of Inspector General (OIG) on inpatient rehabilitation hospitals and units recommends “conducting a demonstration project requiring preauthorization for Part A IRF stays modeled on Medicare Advantage practices (Office of Inspector General, 2018, p. 12).” In addition, the president’s Fiscal Year (FY) 2020 Budget Proposal included a provision that would expand the use of prior authorization specifically for inpatient rehabilitation services in the Medicare fee-forservice program.

In collaboration with the Federation of American Hospitals and the American Academy of Physical Medicine and Rehabilitation, AMRPA has been aggressively working to counter any efforts to impose prior authorization requirements on our most vulnerable patients. As a group, we have met with the Centers for Medicare and Medicaid Services, the Department of Health and Human Services, the OIG and most recently with the Office of Management and Budget. Your AMRPA team and board members have also met with numerous representatives from congressional offices on the topic of prior authorization.

During our meetings, we continued to express our concerns about the OIG report’s recommendations and have always focused on the impact that these recommendations would have on patients’ access to timely and medically necessary inpatient rehabilitation care. Our message has consistently stated that prior authorization leads to improper denials, referrals to less effective care settings that can compromise patient outcomes, and lengthy delays that can cause irreversible harm to beneficiaries. We have also asserted that:

Prior authorization ignores medical judgment and stringent Medicare requirements that govern IRF admissions such as the requirement that qualified physicians need to evaluate the patients against objective pre-admission criteria.

Although MA enrollees are legally entitled to the same benefits as traditional FFS Medicare beneficiaries, they very often experience severe disparities in access due to MA utilization management practices such as prior authorization.

Prior authorization would further jeopardize access to medically necessary IRF care. The Medicare Payment Advisory Commission’s data demonstrates that MA beneficiaries are admitted to IRFs at a rate nearly three times less than traditional Medicare beneficiaries (March 2017).

Each audience AMRPA has spoken with about prior authorization has been receptive to our comments and concerns. We will continue to meet with policymakers and urge them to protect access to medically necessary inpatient rehabilitation services and to reject policies that could delay and deny care.

We know that each of you have your own stories to tell on issues related to prior authorization and we urge you to talk to your congressional offices to express your concerns. Do not hesitate to contact us if you need any help contacting your congressional representatives.

Office of the Inspector General, U.S. Department of Health and Human Services. (2018, Sept), Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements (Report No. A-01-15-00500). https://oig.hhs.gov/oas/reports/ region1/11500500.pdf

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AMRPA Magazine / July 2019

Find new and exciting opportunities in AMRPA’s Career Center.

Our newly updated Career Center provides services and resources to help the medical rehabilitation field meet their professional goals.

All rehabilitation professionals may browse and apply for jobs at no cost, and AMRPA members will receive discounted rates for posting positions.

Visit our Career Center Here:

careercenter.amrpa.org

Begin by creating your free Career Cast account, which can be found on the top right hand corner of the website.

From there, you can upload and manage multiple resumes, browse through hundreds of job postings, and even research salaries of the positions in question! AMRPA members and affiliates may also purchase Posting Packages at a standard, premium, or platinum level.

AMRPA members will receive a 50% discount on all job postings.

For questions about our Career Center, please contact Anna Kruskop, AMRPA Member Services Associate, at akruskop@amrpa.org or 202-207-1120.

AMRPA Magazine / July 2019

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Legislative Update

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

Highlights: »»

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ommittees begin the process of C developing legislative packages focused on health care cost transparency, which includes proposals addressing drug pricing and surprise billing, with the hope of passing a bill before the August recess.

Congressional leadership continue negotiations on how to raise the budget caps, before automatic sequestration spending cuts take effect in January 2020.

A bipartisan group of House lawmakers introduce legislation aimed to improve the prior authorization process in Medicare Advantage.

CMS requests additional public comments on reducing administrative burden to put “patients over paperwork.”

AMRPA continues to advocate for members’ key concerns before top administration officials at CMS and OMB and before Congress.

AMRPA Magazine / July 2019

Cost Transparency Package Coming Together Legislation that addresses health care cost transparency, which includes drug pricing and surprise billing proposals, continues to dominate the health policy discussions in both chambers over the course of the summer. On May 23, 2019, the Senate Health, Education, Labor and Pensions (HELP) Committee Chair Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) released a draft health care package, The Lower Health Care Costs Act, that focuses on banning surprise medical bills, speeding low-cost generic drugs to market, increasing transparency, improving public health, and enhancing health information technology. The HELP Committee is soliciting stakeholder feedback, and Chair Alexander has indicated he plans to hold a legislative hearing the week of June 17, followed by a mark-up on June 25. Due to the influx of comments that date may slip, however. The HELP Committee is working in parallel with the Senate Finance Committee and the Judiciary Committee to potentially combine several drug pricing and other health care proposals into a larger price transparency package with hopes of passage before the August recess. Senate Finance Chair Charles E. Grassley (R-IA) announced that the Finance Committee intends to move forward with releasing a drug pricing bill on June 17 and he expects the president to be supportive.

FY 2020 Appropriations Process Continues Despite Lack of Spending Caps Deal House and Senate leadership continue to negotiate a package that deals with discretionary spending caps and prevents the impending $126 billion in mandatory sequestration cuts. Budget Committee leaders in both chambers have spent weeks negotiating, but a compromise has yet to materialize. Consequently, House Speaker Nancy Pelosi (D-CA) and Senate Majority Leader Mitch McConnell (R-KY) began discussions in mid-May over a two-year budget deal at the leadership level. Any deal is likely to come together no earlier than late summer or early fall.

While the constructs of a Budget Caps deal remain up for debate, lawmakers are markingup FY 2020 Appropriations bills in an attempt to keep the process somewhat on track.

By mid-June, the House Appropriations Committee will have considered all of the 12 Appropriations bills, including the Labor-HHS-Education bill.

During the week of June 10, the House Democrats brought a $1 trillion five-bill “minibus” to the floor that includes Defense, H.R. 2968; Labor-HHS-Education, H.R. 2740; Energy-Water, H.R. 2960; State-Foreign Operations, H.R. 2839; and Legislative Branch, H.R. 2779, as an opening bid to avert a potential government shutdown this fall. As expected, Republicans did not support the package. The House again led with a second minibus that funded seven additional federal agencies and seeks to successfully pass the two remaining annual spending bills by the end of July. This is an ambitious plan, to say the least!

Remarkably, Senate leaders have mostly held off on completing Appropriations without a Budget Caps deal, but the Senate Appropriations Committee may start marking up bills after the July 4th Congressional recess using funding numbers from FY 2019.

Closely connected to the Budget Caps debate are negotiations surrounding the Debt Ceiling. The temporary suspension of the Debt Limit expired in early March. However, the Treasury continues to use “extraordinary measures” to prevent a default on U.S. debt.

Those measures are expected to run out as soon as early summer, putting pressure on Congress to suspend or raise the debt ceiling by the fall. It is possible that a Debt Ceiling increase could be attached to another “must pass” item, including any Budget deal that may come together.

Bipartisan Prior Authorization Legislation Introduced On June 6, 2019, Reps. Suzan DelBene (D-WA), Mike Kelly (R-PA), Roger Marshall (R-KS), and Ami Bera (D-CA) introduced legislation that aims to streamline and standardize the prior authorization process in Medicare Advantage (MA). The Improving Seniors’ Timely Access to Care Act of 2019 (H.R. 3107) would require MA plans to establish an electronic prior authorization program, meet specific transparency requirements, as well as beneficiary protection standards. The bill would also improve the prior authorization process to encourage “real-time decisions” on routinely approved services. H.R. 3107 requires formal notice and comment rulemaking on the development of beneficiary protection standards to ensure plans adopt transparent programs, conduct annual reviews of items and services that require prior authorization, and timely prior authorization determinations, rationales for denials, and that plans require review by qualified medical personnel. “As a doctor, I’m proud to be cosponsoring this long-needed legislation to help relieve administrative burdens on practicing physicians,” stated Rep. Ami Bera, MD, in the press release. “Physicians spend far too much time on burdensome paperwork and seeking authorization on certain items, when they can be spending that time taking care of their patients. This bill modernizes the process, and is a win for physicians and patients.”

CMS Solicits Burden Reduction Comments On June 6, the Centers for Medicare and Medicaid Services (CMS) released a Request for Information (RFI) to solicit additional public comment on ideas for regulatory, subregulatory, policy, practice and procedural changes to reduce administrative burden for clinicians, providers and patients. As part of the agency’s continuing Patients over Paperwork initiative, CMS aims to increase quality of care, lower costs, improve program integrity, and make the health care system more effective, simple and accessible.

Comments are due August 6, 2019.

PACE Regulations Updated On May 28, CMS released a final rule that updates the requirements for the Programs of All-Inclusive Care for the Elderly (PACE) for the first time since 2006. According to the CMS press release, more than 45,000 older adults are currently enrolled in more than 100 PACE organizations in 31 states, and enrollment in PACE has increased by more than 120 percent since 2011. CMS explains that the updated regulations reflect changes to best practices in caring for frail and elderly individuals, as well as new program flexibilities to allow greater use of care teams to provide coordinated care.

CMS to Publish List of Nursing Homes Needing Additional Oversight On June 5, CMS released a statement confirming that it intends to release a list of nursing homes being considered for the Special Focus Facility Program, which is designed to improve underperforming facilities, after Sens. Bob Casey (D-PA) and Pat Toomey (R-PA) urged the agency to make the list public. The program targets nursing homes that need additional oversight due to quality concerns found during required inspections.

The Pennsylvania lawmakers expressed concern that because nursing homes participating in the program are indistinguishable from other facilities, beneficiaries and their caregivers are not made aware of their underperformance issues. This represents another example of Congressional pressure on the agency urging increased Medicare beneficiary access to significant information, including quality. *** June and July represent intensely busy months for lawmakers, especially as a major health care package likely comes together for potential passage before the August recess. We highly recommend that you reach out to your representatives and try to schedule meetings and/or visits to your rehab hospital during the July 4 recess and/or the August recess. Along with the AMRPA Washington office, we are closely watching the development of the price transparency package, and continue to advocate and educate Congressional offices on our concerns with the prior authorization proposal included in the president’s FY 2020 Budget Blueprint, which highlights inpatient rehabilitation services as a target for prior authorization in the Medicare program. Members may be looking for pay-fors in this package, and we need to be diligent in our outreach that prior authorization will limit the access of patients that need medically necessary rehab care.

We need your continued help in explaining and showing members of Congress the value of and the positive health outcomes of rehabilitative care for patients, especially Medicare and Medicaid beneficiaries and persons with disabilities. Please let us know how we can help support your advocacy efforts at home!

AMRPA Magazine / July 2019

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CMS Offers Groundbreaking Settlement to Inpatient Rehabilitation Hospitals and Units The Centers for Medicare and Medicaid Services (CMS) has offered to settle pending appeals with inpatient rehabilitation hospitals and units, commonly referred to as “IRFs” or “IRH/Us.” The settlement amount is 69% for the majority of appealed claims—the highest amount offered to date by CMS in a global industry settlement. In addition, CMS offers to settle two subclasses of appealed claims at 100% of the amount in dispute, which is tantamount to an admission that these claims never should have been denied in the first place.

Peter W. Thomas, JD, Principal, The Powers Law Firm

Ronald S. Connelly Principal, The Powers Law Firm

Christina Hughes, JD, MPH, AMRPA counsel, the Powers Law Firm

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AMRPA Magazine / July 2019

Background For over two years, AMRPA has worked in concert with other key industry stakeholders to reach an agreement with CMS on a voluntary IRF global settlement. AMRPA’s sister organization, the Fund for Access to Inpatient Rehabilitation (FAIR), contributed mightily by shouldering the financial burden of this initiative, and the Federation of American Hospitals (FAH) played a key leadership role and compiled appeals data.

This settlement approach was undertaken primarily due to the historically high rate of success for many IRFs at the Administrative Law Judge (ALJ) level of appeal and the near-complete standstill of the appeals process over the past several years.

Key Points of the Settlement Offer To settle its appeals, an IRF must work with CMS to identify eligible claims and then enter into a final, binding settlement. CMS will accept Expressions of Interest in the settlement between June 17, 2019 and September 17, 2019. IRFs should begin by examining all pending appeals to identify those that may be eligible for the settlement.

Eligible Claims To be eligible for settlement, each denied claim must have been denied by a CMS contractor (e.g., a Medicare Administrative Contractor, a Comprehensive Error Rate Testing contractor, a Recovery Audit Contractor). This means that Medicare Advantage denials, claims that were voluntarily refunded, and claims audited and denied by the Office of Inspector General are not eligible for settlement. In addition, claims denied as part of an extrapolated overpayment are not eligible.

In addition, each claim must have been originally appealed on or before August 31, 2018. This means that the request for redetermination of the denied claim must have been filed on or before that date. The appeal must also either still be pending or eligible for further timely appeal at any stage of the administrative appeals process as of the date of final settlement. These requirements eliminate denials issued any time

after August 31, 2018 from eligibility and any appeals that have been exhausted or withdrawn. Denials upheld by the Medicare Appeals Council or escalated to federal court are also not eligible for the settlement.

Settlement Amounts Two tiers of claims are included in the settlement. For the majority of claims, IRFs will be paid 69% of the net payable amount. (“Net payable amount” is the Medicare approved amount minus any deductible and/or coinsurance. No interest will be paid.) For a subset of claims that were denied solely for one of two very specific reasons, the claims will be settled for 100% of the net payable amount. The claims falling into this second tier must have been denied solely for one of the following reasons: The patient did not meet the threshold for therapy time (i.e., the Three Hour Rule); or The justification for group therapy provided to the patient was not documented in the medical record.

The two categories of claims are dubbed “intensity of therapy” appeals by CMS. Again, reimbursing these denials at 100% is a major victory for the IRF field and clearly demonstrates that these claims were incorrectly denied by contractors.

Other Important Details of the Settlement An IRF must settle all of its eligible claims. IRFs will not be permitted to “cherry pick” by settling only some appeals (presumably the weaker ones) while proceeding to an ALJ hearing on others. Once both parties agree to the list of eligible claims and the settlement levels (69% verses 100%), CMS will have 180 days to pay the IRF. In the unlikely event that CMS fails to pay within that timeframe, then interest will accrue in favor of the provider.

Signing the settlement agreement also constitutes a request by the provider to withdraw the appeals. In past settlements, hospitals have sometimes been required to withdraw their own appeals. Withdrawing the appeals as part of the settlement will save substantial time and effort for all parties. However, if CMS subsequently determines that an appeal is not eligible for the settlement (e.g., the claim is the subject of an OIG investigation), the appeal will be reinstated at the level of appeal where it was formerly pending, in the same place in the appeals queue.

Also, any appeal that was not actually pending as of the time of settlement, where further appeal rights have not yet been exhausted, will be deemed to have good cause for late filing if the claim is ultimately rejected from the settlement.

How Was the Settlement Offer Reached?

It took many months of hard work and negotiation by a variety of stakeholders to reach these settlement terms with CMS. An important impetus to the negotiations was a suit filed by the American Hospital Association (AHA) against the Department of Health and Human Services (HHS) over the ALJ backlog.

Prior CMS global settlements also set precedents for the IRF settlement.

To force the government to resolve the extreme backlog of ALJ appeals, AHA filed suit against HHS in 2014. The FAIR Fund filed two amicus curiae briefs in the suit, supporting AHA with facts and arguments highlighting the specific impact of the backlog on IRFs and their patients. The D.C. Circuit Court of Appeals agreed with the FAIR Fund that the ALJ backlog has a “real impact on health and human welfare.” On November 1, 2018, after many procedural skirmishes and appeals, the district court ruled in favor of AHA, ordering HHS to clear the backlog by the end of fiscal year 2022.

Since the most recent court decision, and largely thanks to additional funding from Congress for additional ALJ teams, the Office of Medicare Hearings and Appeals (OMHA) has reduced the backlog. It appears to be on schedule to eliminate the backlog within the court-ordered deadline, but OMHA will need to continue to make significant progress.

HHS has previously used settlements to reduce the backlog.

OMHA instituted a program for facilitating settlement conferences between appellants and CMS (i.e., Settlement Conference Facilitation); however, this settlement tool has not been widely used by IRFs. Anecdotally, the settlement amounts offered by CMS under the facilitated conferences have been unsatisfactorily low in many instances, making the process unattractive to IRFs expecting most of their denials to be overturned following a hearing before an ALJ. In addition, in 2014 and 2016, CMS offered widespread settlements to acute care hospitals for a particular subset of claims (so-called “inpatient status claims”). This industry-wide settlement offer removed approximately 419,000 appeals from the backlog. By offering settlement amounts of 68% and 66%, CMS induced many hospitals to withdraw their pending appeals.

Seeking to take advantage of the opportunities created by these events, AMRPA, in conjunction with the FAIR Fund and FAH, reached out to HHS in early 2016. Once the AHA appeals backlog litigation produced a victory at the district court for providers, the Department of Justice signaled its willingness to have CMS come to the table to begin negotiations with IRF stakeholders in 2017.

The efforts to negotiate with CMS were not guaranteed to be successful given the IRF industry’s historically high success rate at the ALJ level of appeal and the high settlement percentage sought as a result. Throughout months of negotiations, AMRPA, the FAIR Fund, and FAH persisted, and we are very pleased with the successful negotiation of this global settlement offer, with the highest percentage ever offered by CMS on such a settlement, especially in light of the subset of claims to be settled at 100%.

Conclusion The IRF global settlement offer from CMS is an exciting development for many IRFs that have been waiting in limbo for the resolution of numerous appeals, some for dates of service as far back as 2013 or 2014. We encourage all IRFs with pending appeals to examine whether entering into a settlement on the terms offered is beneficial considering the factors that may impact each IRF differently. This settlement will allow

AMRPA Magazine / July 2019

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many IRFs to take a well-earned sigh of relief and finally resolve longstanding appeals.

AMRPA’s counsel, Peter Thomas and Ron Connelly of the Powers Law Firm, represented the IRF stakeholders in this settlement negotiation. Powers remains available to IRFs who may need

10 AMRPA Magazine / July 2019

assistance in assessing the eligibility of claims, determining the proper settlement percentages for claims, factoring in the potential availability of interest payments for claims decided at ALJ hearings, and generally navigating the settlement process.

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AMRPA Magazine / July 2019 11

Modifications to the CMGs in the Proposed Rule

The IRF Proposed Rule released in April 2019 presents changes to the calculation of the case mix groups (CMGs). CMS plans to change the number of case mix groups and modify the way that section GG and H scores from the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) are used to calculate the CMG by applying weights to the self-care and mobility items.

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

// All providers will need to alter the way they think about the timing and assignment of the section GG and H items in order ensure that their coding appropriately reflects patients’ burden of care.

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Within eRehabData®, we modeled the changes so our subscribers would have an idea of what was coming their way. Using the information in the proposed rule, we present the 2020 Proposed Grouper Model. The recommended updates are based on data analysis from federal fiscal years (FYs) 2017 and FY 2018, which includes a more robust data set that provides more insight into the types of patients that we treat in inpatient rehabilitation hospitals and units. The proposed grouper model indicates what your anticipated case mix index would be based on the patients admitted in the time period you designate. The difference in average expected reimbursement highlights whether you will earn more or less money on average. If you see a negative number, that is an indication that your data collection process will not result in the same average reimbursement that you have now. While negative numbers are eye-opening, observing a positive reimbursement difference does not mean that you are in the clear or that no further action is required. All providers will need to alter the way they think about the timing and assignment of the section GG and H items in order ensure that their coding appropriately reflects patients’ burden of care.

The eRehabData® Functional Scoring Congruency percentage is a measure of how likely your section GG scores are to be similar to your FIM™ scores. The higher the percentage, the more negative reimbursement difference you can expect. A lower congruency percentage may indicate that you are ineffective at capturing your burden of care in the section GG and H items while you are doing a good job of capturing burden of care scores using the FIM™ instrument. Luckily, with the FY 2020 rule’s proposed changes, the national congruency appears to be more favorable for providers. The weighted scale seems to have helped providers achieve greater consistency between capturing burden of care in section GG/H items. CMS’ proposed weighted scale eliminates rolling left and right from the CMG motor score, but we are still required to collect data on that item. The table below indicates the weight assigned to each section GG/H item that is used to calculate the new CMG.

Item

Weight

Eating

2.7

Oral hygiene

0.3

Toileting hygiene

2.0

Shower/Bathe self

0.7

Upper-body dressing

0.5

Lower-body dressing

1.0

Putting on/taking off footwear

1.0

Sit to lying

0.1

Lying to sitting on side of bed

0.1

Sit to stand

1.1

Chair/bed-to-chair transfer

1.1

Toilet transfer

1.6

Walk 10 feet

0.8

Walk 50 feet with 2 turns

0.8

Walk 150 feet

0.8

One-step/curb

1.4

Bladder continence

1.3

Bowel continence

0.7

As I write this article, the May 2019 CMS IRF QRP training has not taken place. I keep describing the CMS definitions for the method of assessment and capture of the usual score as a “mixed message.” I look forward to information in that training that should garner further insight. Once we have clarification, it will be time to begin training your nursing staff so they can get started with section GG scoring. Per CMS, we have three days to obtain a score of each of the section GG items. Further, CMS indicated that the scores that we report on the IRF-PAI should be a reflection of the patient’s burden of care prior to patients benefiting from therapeutic intervention. While maintaining safety, we should be assessing the patient in the manner that they complete the activity based on their prior level of function.

To me, that indicates that we should be recording the score for each section GG item during the first assessment of that item.

We will be sharing our insights with the field as new information becomes available.

Taking into account the new information that we have on the weighted scale for section GG/H items, you should do the following: review your medical record documentation to ensure that your data collection is reflective of the burden of care; include nurses in the initial assessments; and educate therapists and nurses on conducting assessments free of therapeutic intervention. Start now in order to test your tools and the impact of your education. Rely on the eRehabData® analytical tools to highlight opportunities for improvement.

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AMRPA Magazine / July 2019 13

Did You Know?

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14 AMRPA Magazine / July 2019

AMRPA Highlights the Importance of Robust Data in Assessing the Proposed FY 2020 Case Mix Policy

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

In our annual engagement with the Center for Medicare and Medicaid Services (CMS) surrounding the Inpatient Rehabilitation Facility (IRF) prospective payment system (PPS) and Quality Reporting Program (QRP) rulemaking, the American Medical Rehabilitation Providers Association (AMRPA) performs extensive quantitative analysis and deliberation.

Through this process, AMRPA relies heavily on the technical data provided by CMS in order to provide a meaningful and accurate assessment of proposed payment changes and predict the impact of the proposal across the industry.

This year, however, AMRPA is concerned about the lack of technical data provided by CMS in conjunction with the federal fiscal year (FY) 2020 IRF PPS/QRP proposed rule and new case-mix group (CMG) policy. Given that CMS will transition in FY 2020 from using the FIM™ functional assessment items to the Quality Indicator assessment items (the standardized patient assessment data elements, or SPADEs) under IRF-PAI Sections GG and H, technical data is especially critical to help AMRPA analyze the new CMG policy.

To this end, AMRPA sent an initial comment letter to CMS in late May asking the agency to provide specific types of data to help stakeholders understand the full impact of CMS’ proposals. Specifically, AMRPA requested the following categories/types of data: 1) Further Explanation of Motor Sub-Weight Changes, including additional detail on why items that carry over from the FIM™ to the proposed Quality Indicator subweights would see significant changes (for example, why the Eating sub-item weight would change from 0.6 (current) to 2.7 (proposed)). AMRPA also requested more data (such as Section GG/H patient assessment data) to help clarify why self-care items are receiving higher weights under the proposed Section GG/H items and mobility items are receiving lower weights, as this is the inverse of the current FIM™ system.

2) Additional Data on CMG Compression, including information on how certain patient stays will be classified under the new CMGs (particularly among patients in those CMGs that are proposed to be removed). AMRPA also asks for any modeling performed to assess the proposed CMGs’ impact on payments for certain conditions.

3) Supplemental data on the Provider-Specific Impact Analysis File, such as a “data dictionary” or similar tool to help understand how the individual provider data was calculated.

AMRPA will be submitting a more comprehensive comment letter later in the rulemaking process, but submitted this initial letter to ensure timely CMS consideration of the field’s data-related concerns. The full text of the letter follows:

AMRPA Magazine / July 2019 15

May 24, 2019 The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services Hubert H. Humphrey Building 200 Independence Avenue, Southwest Washington, DC 20201 Delivered Electronically via Regulations.Gov RE: AMRPA Initial Comment Letter on Fiscal Year 2020 IRF PPS Proposed Rule [CMS-1710-P] Dear Administrator Verma: This early comment letter is submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) regarding the Centers for Medicare and Medicaid Services’ (CMS) Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) and Quality Reporting Program Federal Fiscal Year (FY) 2020 Proposed Rule (hereinafter referred to as the “Proposed Rule”), published in the Federal Register on April 24, 2019.

AMRPA will submit a more detailed and comprehensive response later in the comment period that addresses all aspects of the FY 2020 Proposed Rule. We are submitting this initial comment letter, however, to request that CMS furnish additional data related to certain provisions in the proposed rule (outlined fully below), as AMRPA believes that this data is critical to stakeholders’ analysis and response. As always, AMRPA appreciates your consideration of our comments on the proposed rule.

As a preliminary matter, AMRPA commends CMS for its responsiveness to the concerns we raised in our FY 2019 proposed rule comments about the use of an unweighted motor score applied to the Quality Indicator (QI) assessment items in the IRF patient assessment instrument (IRF PAI). At that time, we noted that, “void of any explanation or data from CMS to justify otherwise, we cannot perceive how reverting to an unweighted motor score for the proposed FY 2020 CMGs would improve or further refine the IRF PPS.” While we continue to believe that a weighted motor score is more likely than an unweighted motor score to improve/further refine the IRF PPS, we note that stakeholders’ understanding of the rule’s proposed impacts would significantly benefit from additional technical information pertaining to the proposed weighted score and other issues.

We greatly value CMS’ collaboration with AMRPA as major changes are implemented to the IRF PPS, as well as other post-acute care payment systems. To this end, we respectfully ask that CMS and (and the Research Triangle Institute (RTI), as required) timely provide the following data to allow AMRPA to comment meaningfully on the proposed IRF PPS changes for both FY 2020 and future payment years: Additional Explanation of Changes to Motor Sub-Weight Items: AMRPA notes that there are significant changes between the current motor subscore weights (used under the FIM™) and the proposed weights (used for the related Quality Indicator items (SPADEs)) under IRF PAI Sections GG and H). While we understand that the weight of motor items will not be identically distributed under Section GG/H reporting as it was with FIM™, we ask that more information be provided on some notable changes – for example, why the Eating sub-item weight would change from 0.6 (current) to 2.7 (proposed). As a broader issue, AMRPA also notes that self-care items were generally assigned lower weights under the FIM™, with mobility items receiving higher weights. Under the proposed weights applied to Section GG/H items, it appears that CMS is taking the inverse approach – assigning higher weights to self-care items and lower weights to mobility items. AMRPA

16 AMRPA Magazine / July 2019

requests additional justification for this change and data, such as Sections GG/H patient assessment data, as we consider our response to this section of the rule.

Additional Data on CMG Compression: We ask CMS to provide any modeling that was performed to examine how the proposed CMG changes will impact certain patient conditions and payment rates. The rule proposes to remove CMGs in four Rehabilitation Impairment Categories (RICs): Stroke (RIC 01), Traumatic brain injury (RIC 02), Non-traumatic spinal cord injury (RIC 05), and Replacement of lower extremity joint (RIC 08). These conditions represent more than a third of all IRF patients.1 We seek information regarding how patients in the removed CMGs will be reclassified under the proposed CMGs, and the resulting impact/changes to reimbursement rates as a result of these changes. To that end, we request data such as a frequency/distribution table showing how the subset of FYs 2017 and 2018 stays used in RTI’s analysis (N=551,503) were classified under the current CMG system, and how those same stays would be classified under the proposed CMG system. AMRPA would similarly appreciate any additional data CMS and/or RTI can share about the compression observed in the proposed CMGs. Provider-Specific Impact Analysis File: AMRPA requests certain additional data – such as a methodology or “data dictionary” – to help understand how the provider-specific impact analysis file was calculated. For example, AMRPA did not find any clarification in the rule as to whether/which facility-level adjusters were used and the year from which the case-mix was derived. Without this data, our members cannot fully assess how the proposed rule would impact their hospital in FY 2020.

1

AMRPA looks forward to continuing to review the rule and, as noted, will be providing CMS with substantive comments on behalf of our member hospitals later in the comment period.

We appreciate the opportunity, however, to provide these initial comments and we thank CMS in advance for its responsiveness to these articulated concerns, and for its efforts to ensure stakeholders can provide meaningful and timely comments on the FY 2020 proposed rule.

If you have any questions do not hesitate to reach out to Kate Beller, Executive Vice President for Policy Development and Government Relations of AMRPA (202-207-1132, kbeller@amrpa.org); Carolyn Zollar, AMRPA Senior Policy Counsel (202-860-1002, czollar@amrpa.org); or Mimi Zhang, AMRPA Director of Payment Innovation, Quality and Research (202-860-1003, mzhang@amrpa.org).

Sincerely,

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

eRehabData® for Medicare fee-for-services discharges in FY 2018. Accessed May 22, 2019.

AMRPA Magazine / July 2019 17

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#AMRPA 18 AMRPA Magazine / July 2019

A Look at Health System Participation in ACOs and Bundled Payment Models, 2016 In 2015, the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services (HHS) created the Comparative Health System Performance (CHSP) Initiative to study how health care systems promote evidence-based practices in delivering care. The CHSP includes a Compendium of U.S. Health Systems comprised of 626 health systems from around the country.

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

Highlights: »» »» »»

ystem-based hospitals are more likely S to participate in alternative payment models (APMs) Larger systems and investor owned systems show higher APM participation AHRQ has made its U.S. health system database available for download

Earlier this year, AHRQ updated the Compendium to include system-level information about health systems’ participation in alternative payment models (APMs) in 2016. The APMs considered by AHRQ include accountable care organizations (ACOs) across public and private payers, and Medicare’s bundled payment programs such as the Comprehensive Care for Joint Replacement (CJR) model or the Bundled Payments for Care Improvement (BPCI) Initiative. CJR is Medicare’s only mandatory bundled payment model at this time.

This article presents key takeaways from AHRQ’s findings.

System Hospitals Are More Likely to Participate in APMs For its analysis, AHRQ defines health systems as including at least one hospital and at least one group of physicians providing comprehensive care, and who are connected with each other and with the hospital through common ownership or joint management.

ARHQ found hospitals that are a part of a health system were more likely to participate in bundled payment models and contract with payers as part of an ACO: 44% of system hospitals (N=3,421) participate in an ACO contract compared to 13% of non-system hospitals (N=1,509).

28% of system hospitals (N=3,513) participate in a Medicare bundled payment model compared to 8% of non-system hospitals (N=1,528).

System Hospitals

Non-System Hospitals

44%

13%

Commercial

33%

4%

Medicare

26%

9%

Medicaid

5%

1%

28%

8%

CJR

19%

8%

BPCI

10%

1%

ACOs

Bundled Payments

AMRPA Magazine / July 2019 19

Percentage of systems participating in ACOs, by system type

Percentage of systems participating in Medicare bundled payment models, by system type

About half of all health systems in the Compendium (46%) have a hospital that participates in CJR or BPCI. On a system-level, 31% of systems participate in CJR and 20% participate in CJR. Slightly more than half of systems (56%) have a hospital that participates in an ACO contract, with commercial and Medicare contracts being the most common. On a system-level, 10% of all systems are engaged in Medicaid ACOs, 37% in Medicare ACOs, and 42% of systems participate in a commercial ACO. Larger Systems and Investor-Owned Systems Have Higher APM Participation Larger heath systems (defined as having four or more affiliated hospitals) were more likely to participate in ACOs and bundled payment models. Similarly, systems that are investor-owned are also more likely to participate in these APMs. Multistate systems are more likely to participate in ACOs or bundled payment models.

Teaching Systems Are More Likely to Participate in APMs Systems with a high teaching intensity exhibited higher participation in ACOs and bundled payment models: Safety Net Hospitals AHRQ found that health systems’ uncompensated burden is not associated with differences in Medicare bundled payment 20 AMRPA Magazine / July 2019

model participation. Of the 505 systems with low uncompensated care burden, 46% were involved with bundled payment models; of the 118 systesms with high compensated care burden, 45% particiapted in bundles.

With regard to ACOs, systems with lower uncompensated care burden are more likely to particiapte in ACOs. Methods AHRQ determined health system types using data from Medicare’s Healthcare Cost Report Information System (HCRIS), which reflects all U.S. non-federal general acute care hospitals.

Health system types are defined as follows: Ownership: Systems are categorized as primarily public, nonprofit or investor owned based on the majority of nonfederal general acute care hospital beds in the system.

Teaching: Systems are categorized as nonteaching, minor teaching or major teaching based on their resident-tobed ratio across systems’ non-federal general acute care hospitals.

Safety net systems: Systems are categorized as serving the safety net using two measures: (1) systems with a high system-wide uncompensated care burden calculated as the ratio of total uncompensated care to total operating expense across systems’ non-federal general acute care

Multistate Systems

Teaching Systems

Safety Net Systems

hospitals and (2) systems with at least one hospital with a high DSH patient percentage.

Children’s systems: Systems are categorized as having no children’s hospitals, having a children’s hospital but not predominately serving children, and predominantly delivering care at children’s hospitals.

Health systems were defined using the following data sources: American Hospital Association (AHA) annual survey of hospitals data, 2015 SK&A integrated health system database, 2016 QuintilesIMS™ Healthcare Organization Services (OneKey Organizations [HCOS]), 2016 In addition to being identified in one of the data sources, health systems had to meet these three criteria to be included in the final list: have at least one non-federal general acute care hospital; have 50 or more total physicians; and have 10 or more primary care physicians.

AHRQ’s work is intended to be a resource for researchers, policymakers, health system leaders, and others who seek to study health systems. The agency will update the data over the course of the five-year CHSP initiative.

For more information, please see the Compendium of U.S. Health Systems, 2016 here: https://www.ahrq.gov/chsp/data-resources/ compendium.html. The complete Compendium database is available for download as a comma-separate value (CSV) file.

AMRPA Magazine / July 2019 21

2019 AMRPA Schedule of Events CONFERENCE DATES 2019 Fall Educational Conference & Expo in San Diego Sunday, October 13, 2019: IRF Boot Camp October 14-16, 2019: Fall Conference & Expo REGISTRATION OPENS THIS MONTH AMRPA WEBINARS Thursday, September 12, Noon ET Considerations for Adolescents on Adult Inpatient Rehabilitation Units Presented by Sue Harlow, OTD, OT/L AMRPA MEMBERS ONLY CALLS Wednesday, August 21 at 1:00 p.m. ET Wednesday, October 23 at 1:00 p.m. ET Wednesday, December 18 at 1:00 p.m. ET eRehabData® WEBINARS: AVAILABLE TO eRehabData® SUBSCRIBERS ONLY Visit eRehabData.com for more Information.

Please visit www.amrpa.org for registration information.

22 AMRPA Magazine / July 2019

AMRPA Submits Comments on CMS and ONC Proposed Rules Regarding Interoperability On June 3, AMRPA submitted comments to two proposed rules from the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology (ONC). The rules proposed adding regulations to the Medicare Conditions of Participation (CoPs) that would require hospitals to provide electronic patient status notifications to other providers.

The rules also requested information on incentivizing use of interoperable electronic health records in post-acute care, as well as several proposals pertaining to preventing information blocking practices. On the following pages is an abbreviated version of AMRPA’s comments to the agencies.

Introduction As post-acute care (PAC) hospitals, AMRPA members are in a unique position to appreciate the importance of interoperability of health information and the benefits to be realized from the free flow of medical information from one provider to the next in the continuum of care. The vast majority of patients receiving care in an IRH/U are transferred directly from an acute-care hospital. These patients have complex medical conditions and will receive an individualized and intensive course of treatment during their stay at the IRH/U. Having an effective and efficient way to receive and access the patient’s medical records can vastly improve care coordination and create important efficiencies for both the acute-care hospital and IRH/U. Further, most patients continue intensive treatment upon discharge from the IRH/U. Maintaining high quality and durable patient outcomes depends in part on the ability to communicate with downstream providers as patients continue their recovery. Due to IRH/Us’ position in the continuum of care that requires communication with both upstream and downstream providers, AMRPA particularly appreciates HHS’ continued efforts to move the U.S. health care system towards becoming more integrated.

Despite recognizing the importance of interoperability amongst providers, achieving interoperability between IRH/Us and other providers has been challenging. First and foremost, implementation of and updates to electronic health record (EHR) systems are resource-intensive and time-consuming. Much to the disappointment of IRH/Us, they, along with other PAC providers, were not eligible for funding through the Medicare and Medicaid EHR Incentive Programs under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.

As AMRPA discusses further below, it would be fundamentally unfair at present to place the same requirements on PAC providers that are required of other providers, the latter of which have received tens of millions of dollars in incentive payments to establish EHR systems. According to HHS’ own research, PAC providers lag behind their acute-care counterparts (who did qualify for such

1

ougherty, M. Long-Term And Post-Acute Care Providers Engaged In Health Information Exchange: Final Report to the HHS Office of the Assistant D Secretary for Planning and Evaluation. October 29, 2013.

2

emarks on Value-Based Transformation for Post-Acute Care. Azar, Alex M. American Health Care Association/National Center for Assisted Living (June 5, R 2018). (Retrieved from: https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/remarks-on-value-based-transformation-for-post-acutecare.html)

AMRPA Magazine / July 2019 23

along patient information. This allows a clear stream of information to flow with a patient as they transition from a hospital to PAC and beyond. Therefore, and as discussed more thoroughly in the next section, there should be additional funding opportunities for EHR adoption in PAC settings before CMS implements burdensome changes to the CoPs.

funding) when it comes to the adoption of EHR systems due in part to this exclusion.1 HHS Secretary Alex Azar acknowledged this disparity in a June 5, 2018 speech to PAC providers, stating that “the federal government has not always paid the same level of attention to advancing electronic health records in your industry as in traditional healthcare settings.”2 Due to this lack of funding from the federal government, some freestanding inpatient rehabilitation hospitals continue to lack EHRs. Others have invested significant resources adopting EHRs only to find that their health information exchanges are not interoperable with those of other providers, including acute-care hospitals within their own zip code. As AMRPA forewarned HHS during implementation of the Meaningful Use initiative, different care settings have developed different and incompatible EHR systems. As such, AMRPA supports a series of reforms to address these interoperability challenges in the PAC setting, which we outline below.

I. Revisions to the Conditions of Participation for Hospitals and Critical Access Hospitals (CAHs) CMS proposes to amend the Medicare hospital Conditions of Participation (CoPs) to require hospitals to send electronic patient event notifications (EPEN) to other providers with a relevant and established care relationship with the patient in question. CMS proposes that hospitals utilize changes in the admission, discharge and transfer (ADT) status feature in existing EHR systems to trigger a notification. CMS states this new requirement will only apply to hospitals that currently possess EHR systems with the “technical capacity” to generate information for EPENs. As outlined below, this proposal is premature, lacks sufficient clarity, and will therefore impose undue burden on hospitals with questionable benefit to patients.

A. CMS’ Proposal to Amend the CoPs is Premature In response to CMS’ Request for Information (RFI) last year on enhancing interoperability, AMRPA detailed its concerns regarding CMS’ consideration of amending the CoPs to encourage interoperability. AMRPA noted in its letter that a CoP essentially serves as the harshest enforcement mechanism of all – potentially rendering a provider unable to participate in the Medicare program.

Therefore, there are several interim but significant efforts that should be undertaken by CMS, HHS and the health care industry at large to improve interoperability before CMS amends the CoPs to compel hospitals to take burdensome steps to enhance their EHR. Given that IRH/Us were not eligible for Meaningful Use (now Promoting Interoperability) program funds, there is an important subset of hospitals (and of the PAC continuum at-large) that have not yet been financially incentivized to adopt interoperable EHR. Even though acute-care hospitals have been incentivized to adopt EHR, interoperability is most useful when the entire care continuum is capable of receiving and passing

24 AMRPA Magazine / July 2019

In addition to addressing interoperability for downstream providers, efforts also need to be taken to address patient matching difficulties among providers.

As CMS is aware, there is not currently a national Unique Patient Identifier (UPI), as Congress has restricted HHS’ ability to develop such a program. This places significant barriers on providers’ ability to fully utilize transferred health information, even when using interoperable systems. Without the ability to confidentially match transferred data to a patient, the receiving providers rarely incorporate the information being transmitted into a patient’s medical record. This means that even if CMS requires hospitals to generate EPENs, the information may be of little utility to providers who currently lack the ability to confidently match the transmitted information to the correct patient. Therefore, until EPENs can be of more effective use to providers, CMS should refrain from implementing such a far-reaching requirement.

B. CMS’ Proposed CoP Requirements Lack Sufficient Clarity CMS’ proposal to amend the CoPs to require EPENs lacks sufficient clarity and will create additional and unnecessary burden for providers. Based on our review of the proposed rule, it is unclear to which hospitals these requirements will apply, what steps hospitals must take to comply with the rule, and what technical specifications the patient event notifications must meet.

1. CMS Should Clarify Which Hospitals Will be Subject to the New CoP In the proposed rule, CMS states it will only impose the EPEN requirement on hospitals “which currently possess EHR systems with the technical capacity” to generate EPENs. AMRPA is gravely concerned that this distinction lacks sufficient clarity and could lead to confusion and serious administrative burden on facilities. The proposed rule does not indicate where the line is drawn between systems that currently possess or lack the technical capacity to create such notifications. Given each provider’s unique circumstances, the resources required to add this capability could be minor, very extensive, or something in between. Since CMS has not expanded upon where exactly this line will be draw, it is unclear which providers this requirement will ultimately apply.

If implemented, CMS should specifically address how it will determine whether a hospital’s current EHR qualifies as being “currently capable,” and

clarify the expenditures a hospital will be required to incur to activate this feature. CMS should be aware that even those hospitals eventually deemed not required to comply will need to undergo a burdensome examination of their system to determine whether they are subject to the requirement, or presume they are eligible and expend vast resources to bring their systems into compliance. As proposed, CMS may force hospitals to expend vast resources to determine their compliance with and/or satisfy this new CoP. Rather than imposing this burden on hospitals, we urge CMS to take the more gradual and less disruptive step of requiring hospitals that issue EPENs to continue doing so, and to work with the IRH/U industry as CMS seeks to expand the use of EPENs among other providers.

Finally, CMS relies heavily in this proposal on the ADT function, which is an HL7 feature. However, many direct message functions operate outside of the HL7 realm. AMRPA members seek clarity as to whether they must use HL7 integration functions to send notifications or whether they can use other methods. Our member hospitals believe that requiring HL7 integration of all providers would be an almost impossibly burdensome task, and AMRPA therefore urges CMS to clarify that hospitals may generate notifications via other means.

2. CMS Should Provide Flexibility in Complying with this CoP In addition to the lack of clarity regarding which hospitals will be subject to the CoP, CMS is unclear as to how much flexibility providers will have in how they utilize EPENs. CMS states in the proposed rule that it expects providers would use ADT status changes to trigger notification.

However, our member hospitals report that in many instances there may be a more effective way of communicating patient events to other providers. For example, some providers find that the ADT notification is triggered too early, often immediately upon discharge or transfer, which is before a discharge summary or other information can be compiled about the patient. Some providers may prefer the EPEN be triggered by another event, such as completion of the patient discharge summary. Otherwise, the notification may include minimal information for the downstream providers.

CMS should clarify whether providers can use other triggers besides ADT to create patient event notifications.

AMRPA recommends CMS withdraw this proposal, or at the very least provide extensive clarification as to how this CoP implementation will limit potential burden on hospitals. Absent that, and given the draconian consequence of not meeting the requirements of a CoP,

hospitals will be compelled to take resource-intensive steps to ensure they can comply with this proposed requirement.

Further, given the significantly more helpful information offered by events outside of ADT notification (for example, the completion of the patient discharge summary), we think it would be helpful if CMS first engaged with stakeholders to determine the best ways to collect this data prior to moving forward with implementation. Finally, and even if CMS proceeds without modification, this change will have little immediate positive effect given the lack of interoperability across the care continuum. Therefore, the burden of this proposal far outweighs the benefits and should be seriously reconsidered.

II. Provider Digital Contact Information (NPPES Database) CMS proposes to increase the number of providers (both individuals and facilities) with digital contact information in the National Plan and Provider Enumeration System (NPPES) by publicly reporting the names and National Provider Identifiers (NPIs) of those providers who have not input their digital contact information in the NPPES. CMS proposes to begin public reporting in the second half of 2020.

In this proposed rule, CMS notes that it previously finalized a policy, in the 2015 Meaningful Use final rule, to use the NPPES to collect digital contact information from participants in the EHR Incentive Program. In other words, participants that received EHR Incentive funding have had four years to input their digital contact information in NPPES and meet the requirements of this proposal. As CMS is aware, IRH/Us were not included in the EHR Incentive Program nor in its related policies. AMRPA recommends CMS clarify in the final rule that providers who did not participate in Meaningful Use – such as IRH/Us and their employed clinicians – would be exempt from being publicly reported as proposed. This public listing should be based on the clarification of the rule determining what hospitals have EHRs with EPENs or direct messaging capabilities, as we have described above. As hospitals implement these EHR functionalities, then they would qualify for publicly being listed for non-compliance. However, it is unfair for CMS to expect all providers to meet the same compliance standard in 2020 when some providers have had multiple years to comply with this requirement.

III. Information Blocking Proposals As previously discussed, IRH/Us are in a unique position in the continuum of care, often needing to receive crucial health information from upstream providers and also needing to pass health information downstream as a patient continues treatment after discharge from an IRH/U. Therefore, AMRPA is supportive of CMS and ONC’s efforts to limit information blocking practices.

A. Attestation and Public Reporting of Hospitals and Providers Information Blocking Practices CMS proposes to report hospitals and providers that fail to attest that they do not engage in information blocking practices as part of the Promoting

AMRPA Magazine / July 2019 25

Interoperability (PI) and Quality Payment Program (QPP). While AMRPA does not support the more extreme step of amending the CoPs, we find that adding requirements to incentive programs such as the Promoting Interoperability and QPP programs is an appropriate incremental step towards interoperability.

While this could deprive some hospitals of additional funding or business, we believe this is a more appropriate consequence at this still-early stage of interoperability, as opposed to total exclusion from the Medicare program. Therefore, AMRPA encourages CMS to finalize its proposal to publicly report hospitals and providers that fail to attest that they do not engage in information blocking practices.

B. Prohibition on Information Blocking by Health IT Developers ONC proposes to require as a Condition of Certification for health information technology (HIT) developers that they refrain engaging in information blocking practices, and that developers must provide assurances to ONC that they do not engage in such practices.

As AMRPA stated in response to last year’s RFI, our hospitals are supportive of HHS taking steps within the realm of incentive programs to enhance interoperability. This would include ensuring that providers participating in the PI and QPP program, as well as the vendors supplying the systems, are not participating in information blocking practices. This is an incremental step that will not overly burden providers or vendors, while also enhance the overall availability of interoperable HIT systems. Therefore, AMRPA encourages ONC to finalize this proposal.

IV. Inclusion of Price Information within Electronic Health Information ONC proposes to include elements of pricing within electronic health information (EHI). The agency posits that including price information within electronic health information will increase price transparency, allowing consumers to make more informed choices and ultimately bring down costs. However, AMRPA thinks this proposal will be overly burdensome and add little in terms of useful information for consumers.

Similar to AMRPA’s response to CMS’ proposal to require posting of hospital standard charges, AMRPA continues to believe that standard prices or negotiated prices between providers and insurers is of limited use to consumers. As HHS knows, the price to consumers for any given service is dependent on the interplay between the insurer’s costsharing policies, the provider’s price, and the consumer’s unique situation relative to deductibles and other utilization.

Therefore, including a list price, a negotiated price, a price relative to the Medicare rate, or other price information, is of little use to the consumer in knowing their net cost.

While this data provides minimal benefit to consumers, providing this information will be burdensome on providers,

26 AMRPA Magazine / July 2019

particularly for hospitals that provide specialized care like IRH/Us. Given the unique needs of medical rehabilitation patients, it is not unusual for an IRH/U to negotiate rates on a patient-by-patient basis. While all providers would be burdened with entering standard rate information, the burden would be even higher for specialty providers to include specially negotiated rates in EHI. Ultimately, it is payors, and not providers, that hold the keys to the information needed to inform consumers about their cost. Payors have the information on all three aspects needed to make that determination – the covered rate for the services, the cost-sharing responsibilities under the insurer’s policy, and the current utilization of the patient relative to deductibles and other fluctuating cost-sharing arrangements. Therefore, ONC should focus on bolstering insurers’ obligations to provide cost and price information, rather than providers.

If ONC were to finalize this proposal, it would have a ripple effect of administrative burden on providers, with little benefit to consumers. The proposed rule defines EHI in a very broad manner. If price information must be contained in all of these constructions of EHI, hospitals will be overwhelmed with the number of places it would need to insert this information. Further, as explained above, even if ONC more carefully tailors its requirement, the burden of providing this information would provide little useful information to consumers. Therefore, AMRPA recommends ONC not finalize its proposal to include some element of price information within the definition of EHI. V. Request for Information on Advancing Interoperability Across the Care Continuum

A. Incentivizing Adoption As CMS recognizes, PAC providers have not had the access to federal funding to adopt HIT that other providers have had. AMRPA appreciates CMS’ recognition of this disparity and its request for feedback on ways to incentivize HIT adoption. AMRPA recommends that CMS (and if needed, Congress) adopt or provide incentives to support EHR adoption in PAC and other settings excluded from Meaningful Use. As a potential approach, CMS should consider a bonus payment framework that rewards PAC providers for achieving EHR adoption and demonstrating interoperable information exchange. This policy would not exclude PAC providers who have already dedicated considerable financial resources to integrating and adopting EHRs in their institutions. Critically, any policy or initiative CMS implements to incentivize adoption must not come at a cost to PAC providers. In other words, any incentive dollars made available to PAC must not be achieved through a “budget neutral” mechanism that depletes PAC funding from elsewhere in the Medicare program. Needless to say, it would further put PAC providers at an unfair disadvantage if PAC-specific EHR incentive payments were funded by reducing PAC funding elsewhere when no such budget neutral

mechanisms were applied to acute-care providers that received funds under the Meaningful Use incentive program.

The Meaningful Use program has been in place for nearly a decade and, despite progress, interoperability among acute care and ambulatory settings is still not reality. Accordingly, AMRPA recommends PAC providers be afforded an adequate ramp-up period or “glide-path” before they can be held to the same interoperability standards as acute care or ambulatory settings.

B. Standardized Patient Assessment Data Elements (SPADEs) CMS seeks input on whether acute care hospitals and physicians should adopt the capability to collect and electronically exchange a subset of the PAC standardized patient assessment data elements (SPADEs), such as functional status or pressure ulcers/ injuries.

AMRPA has long supported enhancing the collection of patients’ functional status information and functional outcomes across the spectrum of providers and across the Medicare program through measures that are setting-appropriate. Achieving and maintaining functional ability is a critically valuable outcome to patients. While AMRPA fully appreciates CMS’ efforts to expand the collection of functional status data, we are concerned about the agency’s suggested approach to utilize the SPADEs – which were developed for and validated in PAC settings – in non-PAC settings such as acute care hospitals and physician offices. We encourage CMS to reconsider any “plug-and-play” approach and instead develop an appropriate method for adopting PAC SPADEs in other, non-PAC settings.

AMRPA recommends CMS convene a technical expert panel (TEP) as a first course of action to explore these issues. Furthermore, we caution the agency against considering the SPADEs as any form of “gold standard” patient assessment items, despite their current usage across multiple PAC settings. AMRPA encourages CMS to continue identifying or developing assessment items that are minimally burdensome and clinically appropriate for the care setting in which they will be used.

Even in PAC settings, collecting standardized patient assessment data is a relatively recent development, and CMS and stakeholders continue to work diligently on the implementation of SPADEs in order to collect data in a standardized manner. These efforts have entailed extensive provider education and training resources from CMS and from PAC providers to ensure that patients are being assessed consistently and accurately 3

across settings; short of that, the collected data would not be truly standardized and therefore be of questionable utility or value. CMS would need to ensure that non-PAC settings/providers undergo comparable education and training to ensure uniformity and crosssetting consistency in the collection of SPADEs. There are also other technical issues CMS must be cognizant of as it considers integrating SPADEs in other care settings. For instance, PAC providers currently collect SPADEs over a multi-day lookback period consistent with CMS guidance for PAC patient assessments, but this practice would not be feasible in acute-care hospital and ambulatory settings in which patients have shorter lengths of stay. These factors collectively make AMRPA concerned about CMS’ proposal and we recommend the agency reconsider implementation at this time.

C. Measure Gaps and Development AMRPA supports CMS’ work to develop consensus around measure concepts that could inform any evaluation of providers’ engagement in information exchange across settings, as well as the effectiveness of that engagement. As CMS recognizes, the measurement of interoperability has largely focused on the use of certified technology and the percentage of information exchanged. This domain will continue to be relevant if efforts are being made to enhance EHR adoption and exchange capabilities to care settings, such as PAC, that previously were excluded from Meaningful Use funding.

We note that CMS already intends to collect information on PAC providers’ use of electronic patient information transfer via new mandatory quality measures, pursuant to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act3 While AMRPA remains supportive of the agency’s efforts to assess interoperability and identify measure gaps, we oppose the use of mandatory PAC quality reporting programs as the data collection vehicles for this work. This approach unnecessarily adds burden to IRH/ Us when valuable clinician time and attention should be dedicated to addressing the needs of patients. CMS should utilize other avenues to research and otherwise inform its understanding of interoperability issues.

VI. Request for Information on Advancing Interoperability in Innovation Models As part of this proposed rule, the CMS Innovation Center (CMMI) seeks public comment on the principles for promoting interoperability as it considers interoperability requirements for all CMMI models going forward. AMRPA recognizes that CMMI models represent an important potential opportunity to advance progress toward interoperability. However, AMRPA does not support CMMI using innovation models as a “lever” for advancing interoperability, as CMS states in the rule.

I n the proposed FY 2020 Medicare payment rules for the IRF Prospective Payment System (IRF PPS) Skilled Nursing Facility PPS, and Long-Term Care Hospital PPS, CMS proposes to add two Transfer of Health Information measures to the settings’ respective Quality Reporting Programs.

AMRPA Magazine / July 2019 27

There is a high degree of variability in EHR adoption across care settings due to the lack of incentive funding for all care settings. AMRPA is concerned that any move to make interoperability a prerequisite for CMMI model participation would only further exacerbate the existing disparities in EHR adoption and disadvantage those providers and settings (PAC, behavioral health, and community-based services, rural providers) that are already at a disadvantage vis-àvis achieving interoperability. CMS should strive to use CMMI funding as a means of supporting and enabling interoperability across the health care continuum and not use interoperability as a barrier of access to innovation funding.

VII. API Access to Beneficiary Data and Published Provider Directory Data AMRPA supports CMS’ proposal to require Medicare Advantage (MA), Medicaid, and exchange plans to make data on claims, treatment history, and plans’ provider directory data electronically available to beneficiaries through open application program interfaces (APIs). With regard to MA, AMRPA further recommends that CMS provide MA enrollees improved access to information about MA plans’ utilization management strategies such as prior authorization requirements. Prior authorization often has significantly negative impacts on patients’ access to medically necessary care which may also affect beneficiaries’ out-of-pocket costs.

Our member hospitals report that MA prior authorization systemically and detrimentally delays and denies patient access to IRH/U care. Even though MA beneficiaries are entitled to the same benefits as traditional Medicare beneficiaries, MA plans frequently utilize a unique and harmful prior authorization process based on proprietary guidelines for admission to IRH/Us. When Medicare beneficiaries are injured, become seriously ill, or require surgery, they often require medical rehabilitation in an IRH/U to regain functional losses. The majority of IRH/U patients are referred directly from acute-care hospitals, and hospitals strive to discharge patients as quickly as possible when the patient’s condition warrants. However, despite the vulnerable condition of IRH/U patients, even the most expeditious MA plans take one to three business days to respond to a prior authorization request for IRH/U admission. Unfortunately, the initial approval request is often just the first stage of the fight to admit MA beneficiaries to IRH/Us since a large majority of initial requests for IRH/U admission are typically, and often inappropriately, denied. This leaves acute-care hospitals in the precarious position of choosing between extending the

28 AMRPA Magazine / July 2019

stay of the patient (which may not be medically necessary) while an appeal is pursued, or discharging patients to lower-intensity PAC settings in order to open up availability of a hospital bed to accept new patients. Far too often, MA prior authorization leads to improper IRH/U service denials, referrals to less effective care settings that can compromise patient outcomes, and lengthy delays that cause irreversible harm to beneficiaries.

As CMS strives to improve beneficiary access to their health plan data and enhance health plan transparency, CMS must take the necessary steps to educate beneficiaries about the potential negative consequences resulting from MA utilization management strategies such as prior authorization.

Conclusion AMRPA thanks the Administration for continuing to seek ways to improve interoperability and patient access to their health information, and we appreciate the opportunity to provide our comments.

Sincerely,

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

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

Suzanne Kauserud, FACHE, MBA, PT Chair, AMRPA Quality Committee Vice President, Carolinas Rehabilitation – Atrium Health

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Musculoskeletal Disease Second-highest Global Cause of Years Lived with Disability

Highlights: »»

»»

he overall burden of T musculoskeletal disease is primarily due to years lost to disability (YLDs) rather than years of life lost (YLLs).

There is a high disability rate but low death rate of MSK disease.

Data published in the Annals of the Rheumatic Diseases shows that the burden of musculoskeletal diseases (MSK) has increased dramatically during the period 20002015, becoming the second most common cause of years lived with a disability (YLDs) in the world.

The article, The worldwide burden of musculoskeletal diseases: a systematic analysis of the World Health Organization Burden of Diseases Database, analyzed the worldwide burden of MSK diseases using data from the WHO Global Health Estimates Database.

Specifically, the study used WHO data available for the years 2000, 2005, 2010 and 2015, in 183 countries with conditions grouped into 23 categories based on the ICD10. The authors found a significant increase of both the total number and proportion of disability-adjusted life years (DALYs) due to MSK diseases over the past 15 years.

Additionally, the burden of MSK disease is essentially due to disability (YLDs) as opposed to premature death (years of life lost - YLLs), with a strong correlation between MSK disease burden and GDP per capita. These data suggest an increased burden of MSK diseases in high-income countries. Compared to all other categories of DALYs, MSK diseases had the highest impact in Europe.

The total global number of disability-adjusted life years due to musculoskeletal diseases increased greatly from 80,225,634.6 in 2000, to 107,885,832.6 in 2015 (P < .001). During the same period, the total number of years lived with disability rose from 77,377,709.4 to 103,817,908.4 (P = .0008). Also increasing from 2,847,925.2 to 4,067,924.2 (P = .0001) were years of life lost to musculoskeletal diseases.

Disability-adjusted life years related to musculoskeletal diseases were also compared across continents. In Europe, 6.66% of DALYs were related to MSK diseases (IQR = 5.3-7.88) compared with 4.66% (IQR = 3.98-5.59) in the Americas (P < .0001), 4.17% (3.14-6.25) in Asia (P < .0001), 4.14% (2.6-5.57) in Oceania (P = .0008), and 1.33% (1.031.92) in Africa (P < .0001).

Musculoskeletal diseases are the ninth cause of DALYs, the second cause of YLDs, and the 19th cause of YLLs around the world, with an increasing number of MSK diseases mostly effecting Europe. The results confirm that the overall burden of MSK disease is primarily due to YLDs rather than YLLs; or, a high disability rate but low death rate of MSK disease.

Overall, there is a strong association between MSK DALYs and GDP per capita, showing that socioeconomic background is a strong determinant of the MSK disease burden.

These results are extremely important for health professionals, policy makers and national healthcare systems as future health plans are discussed, changed and implemented.

The full abstract is available at http://ard.bmj.com

AMRPA Magazine / July 2019 31

Family Involvement in Inpatient Rehabilitation for Traumatic Brain Injury Patients Highlights: »»

tudy suggests that family S involvement during an inpatient rehabilitation leads to improved outcomes for traumatic brain injury patients

»»

Effective involvement can be achieved through family attendance for a few hours of therapy every week

A recent study published in the Archives of Physical Medicine and Rehabilitation sheds light on the effects of family involvement following traumatic brain injury (TBI).

In the article, Family Involvement in Traumatic Brain Injury Inpatient Rehabilitation: A Propensity Score Analysis of Effects on Outcomes During the First Year after Discharge, the authors sought to answer whether patients with TBI benefit when their families are involved in acute inpatient rehabilitation. The presumption was that family attendance during inpatient rehabilitation sessions facilitates better family understanding of the impact of and deficits associated with the TBI to help prepare for the patient’s return home. While family members can help identify functional activities required of the patient at home so these activities can be factored into treatment, the family nonetheless is coping with many other stressors and issues throughout the rehabilitation process. In light of these competing priorities, therapists are trying to determine whether to encourage families to attend rehabilitation treatment sessions.

With little evidence available on the effects of family involvement on rehabilitation outcomes, the authors felt that an estimate of these effects would assist with decisionmaking with regard to family attendance in therapy. The authors cited research in pediatric rehabilitation research showing that parent training has a positive influence on child outcomes, and studies of adults in post-acute outpatient rehabilitations suggest that family involvement can have an impact on the therapeutic alliance.

Significantly, family engagement in post-acute rehabilitation has also been associated with greater optimism and better emotional health of family members.

Additionally, one study looked at family attendance at inpatient speech therapy sessions and used the Traumatic Brain Injury Practice-Based Evidence (TBI-PBE) multicenter database for evaluation. This database is a collection of data from each rehabilitation treatment session using point-of-care (POC) forms regarding treatment and participation.

The current study uses the same TBI-PBE database to evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to nine months post-discharge. Outcomes of patients whose families attended therapy sessions were compared to patients whose families attended few or none of the sessions. The authors hypothesized that patients whose families attend therapy for a substantive amount of time will experience better community participation, functional independence, and subjective well-being at discharge and during the year following discharge from rehabilitation.

The TBI-PBE multi-center data included a broad range of patient characteristics, details of rehabilitation interventions and the medical course of treatment, and outcomes from 2008-2011. Medical records and point-of-care (POC) forms completed

32 AMRPA Magazine / July 2019

by therapists after each rehabilitation session were used for data abstraction.

Patients included in the study were 14 or older and had sustained a TBI for which they were receiving their first inpatient care. This treatment took place in the designated brain injury unit of one of nine participating rehabilitation facilities in the United States. The number of patients studied was 1,843.

Family involvement was measured through data obtained from POC forms and included attendance by a family member of friend during at least 10% of all treatment minutes provided by occupational, physical, speech or recreational therapists, or by psychologists.

Main Outcome Measures included scores on productivity, out and about, and social relations as well as functional independence measure, satisfaction with life scale, and a patient health questionnaire. Patients whose families attended at least 10% of treatment were more “out and about” in their communities at both three and nine months after discharge (as compared to patients whose families participated less than 10% of the time.)

In addition, improved functional independence in the cognitive area 9 months after discharge was also associated with increased family participation.

Conclusions The authors found multiple indications that family involvement in traumatic brain injury rehabilitation leads to better patient outcomes. Their study also supports efforts to increase family engagement in the rehabilitation process. Importantly, for families struggling to balance involvement in rehabilitation with other responsibilities, the current study offers reassurance that effective involvement can be as little as attending a couple of hours of treatment a week.

For more information on this study, see https://www.archivespmr.org/article/S0003-9993(19)30301-6/abstract.

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OIG Examines Heath IT Use and Care Coordination in Medicare ACOs

Highlights: »»

Accountable Care Organizations (ACOs) use health IT in some form to aid in patient care coordination.

»»

Use of a single electronic health records (HER) system has allowed ACOs to make great strides in achieving seamless care coordination through interoperability.

A report released in May by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) provides insight into the ways that accountable care organizations (ACOs) use and manage health information technology (health IT). The report, Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations, gathered data from six ACOs, four of which were Next Generation ACOs and two that participated in the Medicare Shared Savings Program (MSSP). An ACO is defined as a network of doctors, hospitals or other health care providers that come together voluntarily to coordinate care for their patients.

The OIG conducted this evaluation to help inform efforts from the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) that seek to help ACOs overcome health IT challenges.

Medicare patients often have chronic medical conditions requiring care from multiple providers, and improved care coordination helps ensure that health services can meet patient needs over time and in numerous settings. Care coordination has been identified by CMS as vital to achieving better care, improved health, and lower costs.

// Medicare patients often have chronic medical conditions requiring care from multiple providers, and improved care coordination helps ensure that health services can meet patient needs over time and in numerous settings.

Overall, the report shows that the ACOs visited have used health IT to better coordinate patient care in a variety of ways; although, health IT’s full potential has not been realized.

Background and Care Coordination More than half of Americans over the age of 65 suffer from chronic conditions or medical issues that require substantial support. Due to the high costs associated with this care, providers are challenged to find alternative payment approaches to health care by identifying patients at risk and coordinating their care before costs rise further. ACOs have been identified as one type of alternative approach.

AMRPA Magazine / July 2019 35

The goal of coordinated care is to ensure appropriate and efficient delivery of health care services within and across systems of care, allowing patients to receive the right care at the right time without unnecessary duplication. HHS has focused on advance value-based care an important element of this transformation is maximizing the promise of health IT, by promoting interoperability and removing barriers to care coordination.

Profile of Medicare Accountable Care Organizations Visited Key Takeaways

systems had to find alternative ways to share data; and, physician burnout from managing EHRs and “alarm fatigue” from constant EHR alerts were identified as challenges facing ACOs. Health Information Exchanges (HIEs) create a central repository from which different providers can obtain standardized data. Use of HIEs aids care coordination and can help avoid readmissions and medication errors, while improving diagnoses and decreasing duplicative testing. A key report takeaway about HIEs: some ACOs were able to access large amounts of useful patient data through robust HIEs; however, most ACOs visited had HIEs with little or incomplete data, and thus, still experienced challenges in achieving coordinated care.

Population-level analytics allows providers and health care organizations to use information generated by population health tools as aggregate, electronic health data. Use of this data can help better understand prevention, diagnosis, and treatment while tracking and improving clinical outcomes and lowering health care costs. Key takeaways regarding population-level analytics include: most ACOs visited used population-level analytics for care coordination though fewer ACOs used analytics to customize care to an individual patient’s needs; and, ACOs understand the value of data on social determinants of health, but face difficulty in the collection of that data.

Patient use of health IT holds great promise by allowing patients to become active in their own care. Patients can monitor their conditions, track medications, follow care plans, and communicate remotely with providers. Key takeaways regarding patient-facing health IT tools are: ACOs offer few health IT tools to patients other than online portals to EHRs; and, payment limitations are a challenge to implementing telehealth for ACOs.

Findings of the report fell into four categories with specific recommendations in each: Coordinating at the Point of Care: Electronic Health Records Coordinating at the Point of Care: Health Information Exchanges Coordinating at the Population Level: Analytics Coordinating at the Patient Level: Patients’ Use of Health IT Electronic Health Records (EHRs) offer significant potential to integrate, organize and distribute a patient’s health information amongst providers. This increased access can aid in decisionmaking about a patient’s care with also improving outcomes and avoiding harm. Benefits of EHR use also include reduced costs for duplicative tests or treatments as well as lowered administrative costs. Key takeaways regarding EHRs in this report include: some ACOs used a single EHR system across their provider network, avoiding interoperability challenges; ACOs using multiple EHR

36 AMRPA Magazine / July 2019

Conclusion Overall, the ACOs visited all used health IT in some form to address patient care coordination needs. While the full potential of health IT has not yet been realized, the report concludes that ACOs have taken steps, such as using a single EHR system or other non-health IT methods, in order to achieve seamless care coordination through interoperability.

The impact of health IT tools other than a single EHR system is not as apparent across ACOs. This may be the result of lingering challenges facing ACOs and other health care organizations, such as the limited nature of some HIEs’ data, and the cost of expanding the functionality of tools for care coordination.

The OIG did not make any formal recommendations to CMS or ONC in this report.

The full report can be found at oig.hhs.gov/oei/reports/oei-01-1600180.asp.

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SGTS18007 Rev C

HHS Issues Final Report on Pain Management Best Practices

Highlights: »»

omprehensive pain management C often requires multi-disciplinary coordination among health care professionals.

»»

Achieving excellence in patientcentered care depends on a strong patient-clinician relationship.

»»

Consideration by health systems and clinicians of the pain management needs of special populations is vitally important.

An inter-agency task force convened by the U.S. Department of Health and Human Services (HHS), the U.S. Department of Defense (DoD), and the U.S. Department of Veterans Affairs (VA) with the Office of National Drug Control Policy recently released its final report on acute and chronic pain management best practices. The Pain Management Best Practices Inter-Agency Taskforce is a federal advisory committee established by the Comprehensive Addiction and Recovery Act of 2016. Its mandate is to address acute and chronic pain in light of the ongoing opioid crisis and identify gaps, inconsistencies and updates in order to make recommendations for best practices moving forward.

Process The taskforce consisted of 29 members, including federal agency representatives as well as non-federal experts and representatives from a broad group of stakeholders.

For the review process, the taskforce considered relevant medical and scientific literature and information provided by government and non-government experts in pain management, addiction, and mental health as well as representatives from various disciplines. Additionally, the panel reviewed and considered patient testimonials and public meeting comments, including approximately 6,000 comments from the public submitted during a 90-day public comment period and 3,000 comments from two public meetings.

AMRPA Magazine / July 2019 39

According to the taskforce, patients in the United States with acute and chronic pain have significant difficulties obtaining adequate care. This crisis in care results in deep physical, emotional and societal costs. In fact, 50 million adults in the U.S. have chronic daily pain, while 19.6 million adults have their daily life and work activities disrupted by high-impact chronic pain. Overall, the report states that the cost of pain in the U.S. is estimated at between $560 billion and $635 billion annually.

In addition, the taskforce reported overdose deaths related to prescription opioids, heroin and synthetic heroin—the very medicines prescribed to address acute and chronic pain— have skyrocketed over the past two decades, intertwining the practice of pain management and the attending opioid crisis.

The report noted that in order to treat both pain and opioid abuse simultaneously, patients with painful conditions must be able to work with their health care providers to develop integrative pain treatment plans that balance the optimization of function, quality of life (QOL), and productivity while minimizing risks for opioid misuse and harm.

Findings Comprehensive pain management often requires the work of various health care professionals, including physicians of various disciplines, dentists, nurses, nurse practitioners (NPs), physician assistants (PAs), pharmacists, physical therapists, occupational therapists, behavioral health specialists, psychologists, social workers and integrative health practitioners. The complexity of some pain conditions requires multidisciplinary coordination among health care professionals. In addition to the direct consequences of acute and chronic pain, the experience of pain can exacerbate other health issues, including delayed recovery from surgery or worsen behavioral and mental health disorders.

Achieving excellence in patient-centered care depends on a strong patient-clinician relationship defined by mutual trust and respect, empathy, and compassion, resulting in a strong therapeutic alliance.

Specifically, the report identified the following as characteristics of “excellence in acute and chronic pain care” treatment plans: An individualized, patient-centered approach for diagnosis and treatment of pain in order to establish a therapeutic alliance between patient and clinician.

A multimodal approach that includes medications, nerve blocks, physical therapy, and other modalities for acute pain conditions.

A multidisciplinary approach for chronic pain across various disciplines, using one or more treatment modalities. Five broad treatment categories include: Various Classes of Medications, including non-opioids and opioids.

40 AMRPA Magazine / July 2019

Restorative Therapies, including those implemented by physical therapists and occupational therapists (e.g., physiotherapy, therapeutic exercise and other movement modalities).

Interventional Approaches, including image-guided and minimally invasive procedures.

Behavioral Approaches for psychological, cognitive, emotional, behavioral and social aspects of pain.

Complementary and Integrative Health, including treatment modalities such as acupuncture, massage, movement therapies (e.g., yoga, tai chi) and spirituality.

A biopsychosocial model of care.

Consideration by health systems and clinicians of the pain management needs of special populations such as children/youth, older adults, pregnant women, individuals with chronic relapsing pain conditions, racial and ethnic populations, veterans and patients with cancer who require palliative care.

A thorough patient assessment and evaluation for treatment that includes a risk-benefit analysis when developing patientcentered treatment.

Consideration that stigma can be a barrier to treatment of painful conditions, countered by compassionate, empathetic care centered on a patient-clinician relationship.

Improved education and training about pain conditions and treatment for patients, families, caregivers, clinicians, and policymakers is vital to enhancing pain care.

A focus on addressing access to care barriers including workforce gaps in all pain management disciplines as well as improved insurance coverage and payment for different pain management modalities.

Continued medical and scientific research to: understand the mechanisms underlying the transition from acute to chronic pain; translate promising scientific advances into new and effective diagnostic, preventive and therapeutic approaches for patients; and, implement these approaches effectively in health systems.

Overall, the report is intended to guide the public at large, federal agencies and private stakeholders in the intricacies of effective pain management for acute and chronic pain, particularly as it relates to opioid use and resulting complications.

For the full report, see https://www.hhs.gov/sites/default/files/ pmtf-final-report-2019-05-23.pdf.

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