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Who Are We and Where Is Medical Rehabilitation During a Time of Transition?
1COPYRIGHT 2016, AMRPA, WASHINGTON, DC
2016 Conference
September 28, 2016 8:30-10:00 EST
Hershey, PA
Presenter:
Carolyn C. Zollar, MA, J.D.
Executive Vice President of Government
Relations and Policy Development
czollar@amrpa.org
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 2
State of the Field
Congressional Action
State of Payment and Quality Measures
Audit Agony
Managed Care
New Twists
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 3
Why Are We Talking About
Post Acute Care?
Why We Pay Attention: Medicare – Single Largest Purchaser of Personal Health Care
Medicare
23%
Medicaid
17%
Other Third-Party Payers
9%
Private Health Insurance
34%
Out of Pocket
13%
Other Insurance
4%
4
Total: $2.6
Trillion
Source: MedPAC 2016 June Data Book, pg. 3 COPYRIGHT 2016, AMRPA, WASHINGTON, DC
State of the Field:
Medicare Participating Post-Acute Care Providers as of 2016
COPYRIGHT 2016, AMRPA, WASHINGTON, DC5
Type of 1996 1998 2000 2002 2004 2006 2008 2010 2012 2013 2014 2015 2016
Provider
Skilled 15,553 15,035 14,825 14,792 14,929 15,006 15,041 15,067 15,129 15,685 15,712 15,189 15,233
NursingFacility (SNFs)
Home 9,886 9,386 7,528 6,935 7,341 8,587 9,382 10,945 12,121 12,384 12,612 12,463 12,318Health
Agency (HHAs)
Rehabilitation 1,048 1,097 1,128 1,295 1,359 1,229 1,195 1,189 1,161 1,162 1,161 1,172 1,179
Facilities
(Hospitals &Units)
Long-Term 185 207 253 273 317 393 393 428 437 436 430 424 427
Care
Hospitals
(LTCHs)
Comprehensive 403 550 516 544 638 627 517 401 295 268 234 219 207
Outpatient
Rehabilitation
Facilities
(CORFs)
Source: Centers for Medicare & Medicaid Services (CMS) OSCAR Database
As of February 2016, CMS
State of The FieldInpatient Rehabilitation Facilities Statistics
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2001 2003 2005 2007 2009 2011 2012 2013 2014 2015 2016
Total IRFs* 1,157 1,211 1,231 1,202 1,195 1,169 1,161 1.162 1,161 1,172 1,179
Hospitals 214 215 217 219 224 236 236 243 246 256 267
Units 943 996 1,014 983 971 933 925 919 915 916 912
Total Beds* 35,116 36,785 38,765 38,389 37,943 38,345 37,947 38,265 38,311 39,072 39,320
Hospitals 12,760 13,513 13,956 13,961 14,281 15,004 14,936 15,421 15,530 16,034 16,383
Units 22,356 23,272 24,809 24,428 23,662 23,341 23,011 22,844 22,781 23,038 22,937
*CMS OSCAR Reports to AMRPA
COPYRIGHT 2016, AMRPA, WASHINGTON, DC7
Congressional Action
COPYRIGHT 2016, AMRPA, WASHINGTON, DC8
• FY 2017 Appropriations by September 30
• Continuing Resolution/Omnibus Bill ?
• Value Based Purchasing Legislation
– Impact on PAC Providers
– September 7, 2016 Hearing
– Pending Bill H.R. 3298
Congressional Action
COPYRIGHT 2016, AMRPA, WASHINGTON, DC9
• Lame Duck Session Expected
• Bill Revisions
Withhold 5% vs 8%
No Cross PAC Comparison
Repeal FY 2018 1% Market Basket Reduction
Congressional Action
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State of Payment
Quality Reporting
and
Rule Proposed Rule Correction Notice Final Rule
Hospital Inpatient PPS April 27, 2016 August 22, 2016
Hospital Outpatient PPS July 14, 2016
Inpatient Rehabilitation
Facilities PPS April 25, 2016 August 5, 2016
Home Health Agencies PPS July 5, 2016
Long Term Care Hospitals PPS
MS-LTC- DRG PPS
April 27, 2016 August 22, 2016
Skilled Nursing Facilities PPS April 25, 2016 August 5, 2016
Psychiatric Hospitals PPS August 1, 2016
Physician Fee Schedule July 15, 2016
Source: CMS Prospective Payment Systems - General Information website
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/index.html
FY 2017
Medicare Prospective Payment Systems Rules Status
Copyright 2016, AMRPA, Washington, DC
* All dates are as of publication in the Federal Register
11
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Continued Death By a Thousand Slashes
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IRF PPS FY 2017 Final RuleAugust 5, 2016
FY 2017 IRF PPS Final Rule Snapshot
FY 2014 Final FY 2015 Final FY 2016 Final FY 2017
Final
Standard Payment Rate $14,846 $15,198 $15,478 $15,708
Outlier Threshold $9,272 $8,848 $8,658 $7,954
Labor Share 0.69494 0.69294 0.71 70.9
Wage Index: All Providers Moved To New CBSAs; 19 Rural Hospitals Continue
Transition Over 3 Years; Paid 1/3 of Rural Adjustment in FY 2017
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*Changes in Weights May Increase Payment Overall: Changes in Presumptive Methodology Codes May Decrease Admissions and Revenue
FY 2017 IRF PPS Final Rule:
Facility Adjusters - Yet Again No Changes
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To Recognize Provider Costs Not Included In CMG Weights
LIP Factor
Frozen
0.3177
Rural Percentage 14.9 %
Teaching Factor 1.0163
Frozen at FY 2014 Levels
When Will It Reexamine Them?
No Hints
Outlier Threshold
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$7,984 for FY 2017 From $8,658 in FY
2016
Maintains Payment at Three Percent (3%)
of Total Estimated Payments for FY 2017
In Past Years, Payment Has Not
Reached the 3% Level and the Balance of
the Funds are Returned to the
Treasury
Estimated Total of $117 Million from FY
2011 to 2016 Returned to the
Treasury
Outlier Payment: 80% of Difference
Between Estimated Cost and Adjusted CMS Payment and Outlier Threshold
CMG Weights, Lengths of Stay and Comorbidities
•Case Mix Group Weight Updates with FY 2014 Cost Report Data and FY 2015 Claims Data
•99.7% of Cases Affected Would Be Changed By Less Than 5%
•Lengths of Stay Updated and Standard Deviations are on the Website
•LOS is to Determine Transfer Payments Only!
•List of Tier Comorbidities Found on CMS Website -https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html
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CMS Reevaluates Comorbidities Under IRF PPS
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• CMS Called for Stakeholder Comment on Comorbidities
• June 16 Open Door Forum
• Looking at ICD-10-CMs
• Comments Due September 30, 3016
• AMRPA Workgroup
• What Comorbidities Cost $?
• IRF PAI Item 24; What About Item 47?
IRF PPS Standard Payment AmountsYear Payment Rate Percentage Change from Prior Year
FY 2004 $12,525 + 2.7%
FY 2005 $12,958 + 3.5%
FY 2006 $12,762 - 1.5%
FY 2007 $12,981 + 1.7%
FY 2008 $13,034 + 0.4%
FY 2009 $12,958 - 0.6%
FY 2010 $13,627 - 0.3%
FY 2011 $13,860 + 1.7%
FY 2012 $14,076 + 1.6%
FY 2013 $14,343 + 1.9%
FY 2014 $14,846 + 3.5%
FY 2015 $15,198 + 2.4%
FY 2016 $15,478 + 1.8%
FY 2017 $15,708 +1.48
19COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Difference Between Medicare Payment and Provider Cost for
FY 2017Based on FY 2017 IRF PPS Final Rule (includes outlier payments)
Payment is lower than cost
Payment is higher than cost
Source: CMS FY 2017 IRF PPS Final Rule Rate Setting File
© AMRPA, Washington, DC, 2016
Changes from 2016 to 2017
AL
AZ AR
CA CO
FL
GA
ID
IL IN
IA
KSKY
LA
ME
MI
MN
MS
MO
MT
NENV
NM
NY
NC
ND
OH
OK
OR
PA
SC
SD
TN
TX
UT
VA
WA
WV
WI
WY
AK
HI
MA
NHVT
DEMD
NJ
RICT
MO, MS, OH, NC, SD, MI
None
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FY 2015 FY 2016 FY 2017
No. of Facilities (US) 1,142 1,135 1,133
Total Estimated IRH/U Payment $7.59 B $7.74 B $8.08 B
Payment Per Discharge $19,679 $20,233 $20,669
Estimated Cost Per Discharge $19,588 $19,890 $19,806
Weight Per Discharge Avg. 1.1889 1.1893 1.1952
Wage Index Avg. 0.9550 0.9525 0.9533
eRehabData® Average Medicare CMI 1.2917 1.3169* N/A
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CMS Rate Setting Files
*2016 to date
All payments include outliers.
Sources: FYs 2015-2017 Final Rate Setting Files, CMS; eRehabData®
Why It is Important to Keep an Eye on the PPSs
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BPCICJR
ACO
Fee For Service PPSs
EPM:
Cardiac
The IRF PPS, SNF PPS,
LTCH PPS,
HH PPS and IPPSSHFFT
Pay to ReportPay for
Performance (P4P)
Public Reporting
“IRF Compare”
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Three Reporting Sites/Methods Continue
Via IRF PAI
(Move to CY Basis)
•Pressure Ulcers
•Falls
•Change in Self Care Score
•Change in Mobility Score
•Discharge in Self Care Score
•Discharge in Mobility Score
•Admission and Discharge Functional Assessment
•Drug Regimen (10/1/18)
Via NHSN
(CY Basis)
• CAUTI
• Healthcare Personnel Vaccinated
• Influenza Vaccination Rates
• MRSA
• C. Diff
Via Claims Data
• All 3 Readmission Measures
• Discharge to Community
• MSBP
24COPYRIGHT 2016, AMRPA, WASHINGTON, DC
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FY 2012
IRF PPS Final
Rule
FY 2013
OPPS/ASC Final Rule
FY 2014
IRF PPS Final Rule
FY 2015
IRF PPS Final Rule
2 Measures 2 Measures Revised 3 New Measures 2 New Measures
• CAUTI (NQF
#Q318).
• Pressure
Ulcers (NQF
#0678).
• CAUTI (NQF
#0138) Final
Version Adopted.
• Pressures Ulcers
Revised and
Adopted (NQF
#0678).
• Influenza Vaccine Among Healthcare
Personnel (NQF #0431) for 2016,
annual increase.
• All Cause Unplanned Readmissions for
30 Days Post IRF Discharge for FY
2017 increase. (NQF #2502)
• Patients Given the Vaccine (NQF
#0680) for FY 2017 increase.
• NQF endorsed Pressure Ulcers (NQF
#0678) for FY2017 increase.
• MRSA measure
(NQF #1716)
• Clostridium
difficile infection
measure (NQF
#1717)
• These measures
affect FY 2017
payment
adjustments
IRF Quality Measures: Expansion/Burden?
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FY 2016 IRF PPS Final Rule
8 Measures (6 New Measures Required by the IMPACT Act)
Newly adopted IRF QRP Measures affecting FY 2018 Adjustments to IRF PPS Annual Increase Factor and Subsequent Year Increase
Factors:
• NQF #2502: All Cause Unplanned Readmission Measure for 30 days Post- Discharge from IRFs.4 2
• NQF #0678: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (short stay)4 3
• NQF #0674: An Application of Percent of Residents Experiencing One or More Falls with Major Injury (long stay) 5 3
• NQF #2631: Endorsed on July 23, 2015: An Application of Percent of LTCH Patients with an admission and Discharge Functional
Assessment and a Care Plan that Addresses Function.5 3
• NQF #2633: Under review: IRF Functional Outcome Measure: Change in Self-care Score for Medical Rehabilitation Patients.6 3
• NQF #2634: Under review: IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients.6 3
• NQF #2635: Endorsed on July 23, 2015: IRF Functional Outcome Measure: Discharge Self-care Score for Medical Rehabilitation
patients.3
• NQF #2636: Endorsed on July 23, 2015: IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation
patients.3
IRF Quality Measures
Footnotes
1. Using CDC/ NHSN.
2. Medicare Fee-for-Service claims data.
3. New or modified IRF- PAI items.
4. Previously adopted quality measure that was re-adopted for FY 2018 and subsequent years.
5. Not NQF- endorsed for the IRF setting
6. No NQF – as of 8/2015- endorsed CMS submitted the measure for NQF review in November 2014
COPYRIGHT 2016, AMRPA, WASHINGTON, DC
27
FY 2017
IRF PPS Final Rule
5 New Measures Required by the IMPACT Act
Total 17 Measures Collected on October 1, 2016
• Discharge to Community
• Medicare Spending Per Beneficiary
• Potentially Preventable 30 days Post IRF Discharge Readmission Measure
• Potentially Preventable within IRF Stay Readmission Measure
• Drug Regimen Review (October 1, 2018)
IRF Quality Measures
All on IRF PAI v. 1.4 October 1, 2016 and More To Come!
CMS Held Two Training Sessions to Date –
IRF Quality Reporting Training Materials Available:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/IRF-Quality-Reporting/Training.html
August 23 Public Reporting Webinar Materials:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/IRF-Quality-Reporting/Downloads/IRF-LTCH-Public-Reporting-
Webinar-8-23-16.PDF
IRF Quality Measures and Reporting
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Illinois
• IRF Training Manual v 1.4, Quality Indicators, Section 4, pg. J-I -
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/InpatientRehabFacPPS/IRFPAI.html
• Check Website for Frequent Updates
Question: “What Is the Definition of Intercepted
Falls?”
Intercepted Falls Per CMS
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Illinois
• Intercepted Falls An Issue:
“The definition of a fall provided in the manual is: an unintentional
change in position coming to rest on the ground, floor, or onto the next
lower surface (e.g., onto a bed, chair, or bedside mat). An intercepted fall
is considered a fall. An intercepted fall occurs when the patient would
have fallen if she had not caught him/herself or had not been intercepted
by another person.
The definition of a fall and the examples provided in the IRF-PAI
Training Manual are to assist a clinician in using professional judgement
to distinguish whether a fall (or intercepted fall) occurred.
Intercepted Falls Per CMS
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• Intercepted Falls An Issue (cont’d):
We understand that challenging a patient’s balance and training them to
recover from a loss of balance is an unintentional therapeutic intervention. We
do not consider these anticipated losses of balance that occur during a
supervised therapeutic interventions as intercepted falls.
It is not our intention to limit patient’s rehabilitation progression in any way.
Our intention is to maximized patient safety and capture events that represent
threats to patient safety. Only those falls with “major injury (item 119900C.) is
used in the calculation of the Quality Measure: Percent of Residents
Experiencing One or More Falls with Major Injury.”Source: CMS Helpdesk
Intercepted Falls Per CMS
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 31
IMPACT Act Three Phases of Quality and Resource Use Measure Development and Implementation:
Already Published in FY 2016 and FY 2017 Final Rules
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• Measure Specifications
• Data Collection
• Data Analysis
Phase 1
• Feedback Reports to ProvidersPhase 2
Public
Reporting of
PAC Performance
in the Measures
Phase 3
Public Reporting Overview Graphic
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CASPER Reporting
Reporting
Quality Measure (QM)
Reports
Review & Correct Reports
Provider Review Reports
IRF Compare
Confidential Reporting Public Reporting
Provider Final Validation Report
Provider Threshold Reports (PTR)
Compliance
Review Period September 1-September 30
In CASPER Reporting System
CMS Posted Provider Review Reports
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 34
Make Sure You Review Your Report
For more information, including instructions on how to access preview reports and how to submit a
Review Request to CMS, please see the IRF Quality Public Reporting Website.
If you have questions, please contact the IRF Public Reporting helpdesk: IRFPRquestions@cms.hhs.gov
FY 2017 Final Rule Establishes Data Review and Public Reporting Policies per the IMPACT Act
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 35
Process for Claims Based Data
• Calculated Annually
• Available Annually
• Preview Reports Are for Feedback But Not Review and Correction
• Discharge to Community
• Medicare Spending Per Beneficiary
• Potentially Preventable 30 days Post IRF Discharge Readmission Measure
• Potentially Preventable within IRF Stay Readmission Measure
FY 2017 Final Rule Establishes Data Review and Public Reporting Policies per the IMPACT Act
Process for IRF PAI Reported Data
• CMS Will Provide Feedback Reports After 4.5 Months Correction Period Ends
• Assessment-Based Measures – 2016:
• Percent of Residents with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678):
• Data Collection Began: 10/1/2012
• Public Reporting: Initial post of Quality Data is for Patients Discharges 01/01/2015-12-31/2015 and Will Begin Fall 2016
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 36
Quality Measures - 2016
• CDC National Healthcare Safety Network (NHSN) Outcome Measures
National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138):
•Data collection began: 10/01/2012
•Public reporting: Initial posting of quality data is for patients discharged 01/01/2015–12/31/2015 and will begin fall 2016.
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 37
Quality Measures - 2016
• Claims-Based Measures:
All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (IRFs) (NQF #2502)
Initial posting of quality data is for patients discharged 01/01/2013–12/31/2014 and will begin fall 2016.
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 38
Provider Preview Reports
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• Contain facility-level quality measure data.
• These are automatically generated and saved into your provider's shared folder in the CASPER application.
• Provider Preview Reports are available about 5 months (4.5 months data correction period + 0.5 months preview report generation period) after the end of each data collection quarter.
Provider Preview Reports
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 40
• Data collection period has ended so providers are not able to
correct the underlying data in these reports.
• There will be a 30-day preview period prior to public
reporting which will begin the day the reports are issued to
providers via their CASPER system folders.
• Providers Must Request CMS Review Before End of Review
Period
Provider Preview Reports
Important Notes:
Please review the data about your hospital.
Providers may email the CMS Public Reporting Help Desk if they have questions related to the report at: IRFPRquestions@cms.hhs.gov. or LTCHPRquestions@cms.hhs.gov.
The order of the measures may not represent the order in which they will be displayed on the Compare websites.
The titles of the measure(s) are not the consumer language titles that will appear on the Compare websites.
The crosswalk between these titles will be available on the Compare websites.
COPYRIGHT 2016, AMRPA, WASHINGTON, DC 41
IRF Resources
• Assessment Submission: User Guides & Training page on the QIES Technical
Support Office (QTSO) Web site: https://www.qtso.com/IRFtrain.html
• CASPER Reports: IRF User Guides & Training page on the QIES Technical
Support Office (QTSO) Web site: https://www.qtso.com/IRFtrain.html
•IRF Public Reporting Help Desk Email: IRFPRquestions@cms.hhs.gov
• CMS August 23 Webinar: Quality Reporting Program Provider Training
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/IRF-Quality-Reporting/Downloads/IRF-LTCH-Public-Reporting-
Webinar-8-23-16.PDF
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Public Reporting Starting CY 2017
1. Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)
• Publicly displayed rates are based on four (4) rolling quarters of data
• Would use MRSA bacteremia events that occurred through CY 2015
• Publicly-displayed rates would be updated quarterly
2. Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)
• Publicly displayed based on four (4) rolling quarters of data
• Would use CDI events that occurred through CY 2015
• Publicly-displayed rates would be updated quarterly
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Public Reporting Starting CY 2017
3. Influenza Vaccination Coverage Among Healthcare Personnel (NQF #0431)
• Publicly displayed data would include personnel working in the IRH/U beginning with the 2015-2016 influenza season (October 1, 2015 – March 31, 2016)
• Would use data beginning with the 2015-2016 influenza season
• Publicly-displayed rates updated annually
4. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (NQF #0680)
• Public data would be displayed for patients in the IRH/U, beginning with the 2015-2016 influenza season
• Publicly-displayed rates updated annually
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The two influenza measures (NQF #0431, NQF #0680) will begin with the 2015-2016 influenza vaccination season. CMS
will display rates annually for the Percent of Residents or Patients Who Were Assessed and Appropriately Given the
Seasonal Influenza Vaccine (Short Stay) (NQF #0680).
CMS Issues Non Compliance Letters for FY 2017 Payment
• Letters Were Sent July 20
• You Must File for Reconsideration by August 19 by Email to IRFQRPReconsiderations@cms.hhs.gov
• Responses in September
• You Can Also File for Exception or Extension Request
• If You Are Dissatisfied with the Reconsideration You Can File An Appeal with Provider Reimbursement Review Board (PRRB)
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ICD-10 CM Issues
•Codes Pertaining to Brain Injury Not Included In Presumptive Compliance Methodology
•Effects Providers’ Ability to Meet 60% Rule Using Presumptive Compliance
•Must Then Use Medical Review
•Affects IGC Codes 2.21 and 2.22
•CMS Made No Changes in FY 2017 Final Rule
•AMRPA Continuing to Object
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47
CERT
PSC
MAC
ZPIC
RAs and MACs: WILL THIS TORTURE EVER END?
UPIC
RA
MICSMERC
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Recovery Auditors Approved Audit Issues
•Region A; Performant Recovery: https://www.dcsrac.com/IssuesUnderReview.aspx
•Region B; CGI Federal, Inc: https://racb.cgi.com/Issues.aspx
•Region C; Connolly: http://www.connolly.com/healthcare/pages/ApprovedIssues.aspx
•Region D; HealthDataInsights: https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx
48COPYRIGHT 2016, AMRPA, WASHINGTON, DC
MAC, CERT Denials Increase
Denials Based on “Too Much” Group
Therapy
Too Much of One Type in Group (e.g.
PT, OT, SLP)
No Official CMS Definition of Group, Violation of APA?
CMS Says:
• It Has Not Seen Any Evidence That Contractors Are Misinterpreting Its Policy Guidance
• It Will Let Appeals Process Work “As Designed”
49COPYRIGHT 2016, AMRPA, WASHINGTON, DC
ALJ Backlog: OMHA Paralyzing Delays
OMHA Oversees ALJs
Takes 10 Years to Clear Backlog with
Current Staffing
Average Processing Time in 2016, 808
Days
OMHA Trying Pilots to Reduce
Backlog
Providers Can Settle if Wish
50COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Outpatient Therapy Issues
CY 2017 Medicare Physician Fee Schedule◦Final rule expected around November 1, 2015
◦ Issues: New PT and OT codes, potentially misvalued services
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)◦Extended the therapy cap exceptions process through December 2017
◦ AMRPA advocates for full repeal of caps
◦Eliminated manual medical review of all claims over the $3,700 threshold
◦Created a “targeted” review process for providers with “aberrant” billing patterns
◦Prohibits the use of Recovery Auditors to conduct the reviews
51COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Outpatient Therapy Issues
• MACRA Repealed SGR
Replaced with New Payment Policy Phased in Over Years
New Terms:
Merit-Based Incentive Payment System (MIPS)
Advanced Payment Models (APMs)
52COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Outpatient Therapy Issues - Targeted Medical Reviews
Providers with a high percentage
of patients receiving therapy
beyond the threshold as
compared to their peers during
the first year of MACRA.
Therapy provided in skilled
nursing facilities (SNFs),
therapists in private practice,
and outpatient physical
therapy or speech-language
pathology providers (OPTs) or
other rehabilitation providers
CMS: “Of particular interest in this
medical review process will be the
evaluation of the number of
units/hours of therapy provided in a
day.”
Claims will be selected for review based on:
StrategicHealthSolutions, LLC: The Supplemental Medical Review Contractor (SMRC) tasked with conducting these reviews
February 9, 2016: CMS issues guidance outlining the targeted medical reviews process
53COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Outpatient Therapy Issues - Targeted Medical Reviews
SMRC will send one ADR; Limited to 40 claims per
provider
SMRC has 45 days to respond with its decision. After 45 days, the SMRC will take no further action (but can turn it over to the MAC for further review)
54COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Outpatient Therapy Issues - Targeted Medical Reviews
SMRC Discussion Period: Provider may engage the SMRC in a discussion period to provide additional details that may overturn the initial determination in the provider’s favor
Unresolved denials will go to the MAC for
recoupment
Initial reviews are targeting services provided in SNFs, private practices, and outpatient facilities
• Home health claims under Part B are not being reviewed
55COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Targeted Manual Review Resources
CMS’ Therapy Cap website: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/TherapyCap.html
StrategicHealthSolutions, LLC: https://strategichs.com/smrc/project-y4p0430-macra-outpatient-rehabilitation-therapy-cap/
Sample ADR Request Letter: https://strategichs.com/2014WP/wp-content/uploads/2016/08/wY4P0430MACRAADRLtrPUBWEB071816f.pdf
56COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Other MACRA Activity
• Proposed rule issued May 9, 2016
• Final rule would be issued November 1, 2016 if CMS maintains January 2017 start date
Quality Payment Program NPRM – The framework for MIPS and APMs
• MACRA requires Part B claims submitted on or after January 2018 to include a “patient relationship code”
• Developing patient relationship codes and classifications is a new undertaking for CMS
May 2016: CMS RFI Patient Relationship Categories and Codes
AMRPA advocates that therapists along the continuum of care be recognized appropriately in all MACRA initiatives
Both AMRPA comment letters are available on www.amrpa.org
57COPYRIGHT 2016, AMRPA, WASHINGTON, DC
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Managed Care &
Rehabilitation
59COPYRIGHT 2015, AMRPA, WASHINGTON, DC
Continued Reports of Increasing
Denials
AMRPA Denials Management
Committee Survey
Continued Use of Proprietary Guidelines
MA Trends in eRehabData®
Patients 2011 20157.8% 9.4%
Denials
2011 201426% 30%
Managed Care & Rehabilitation
OIG Issues Trend Report on Adverse Events: This One Focuses on Rehab Hospitals
•Reports on Acute Care Hospitals and SNFs Issued Previously; LTCHs To Come
•Uses Data from March 2012
•Sample: 417 Beneficiaries Out of 12,328 Beneficiaries; 182 Beneficiaries Flagged for Possible Adverse Event
•Estimated 29 Percent of Patients Experienced Adverse or Temporary Harm Events
•Less Than 1% Died
•Medication Reconciliation and Patient Care Largest Categories
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OIG Issues Trend Report on Adverse Events: This One Focuses on Rehab Hospitals
Adverse Events Preventable
IPPS 27% 44%
SNFs 33% 59%
IRFs 29% 46%
Methodology: Global Trigger Tool
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• 46% of These Events Were Preventable
• Findings for Acute Care and SNFs
Newest Twists
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Chubby Checker
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(ACT)
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FFS
Quality
ACA
Payment
Reform
APM
Shift Risk
Bundling
Episodes
Population
Based
PaymentIMPACT ACT
Healthcare Environment:
Changes in Medical Rehabilitation
Value
Global Budgets
COPYRIGHT 2016, AMRPA, WASHINGTON, DC
IMPACT Act: Standardizing Data, Interoperability and Quality Measures
IMPACT ACT OF 2014
Step 2
Standardized Patient Assessment Data (SPAD)
Step 3
Create Post Acute Care
Prospective Payment System
Step 1
Quality Measures and Resource Use
Along the Way -Interoperability
65
2016 2017 2018 2019 2020 2021 – 2022
Oct 1, 2016IRH/Us Start Reporting:• 3 of 5 Quality Measures
(Functional Status, Skin Integrity, Falls)
• All Resource Use Measures
Jan 2016CMS Promulgates Regulations to Modify COP (once every 5 years)
2016 Reports: • Features of a PAC PPS (MedPAC, June 30)• Collecting Race & Ethnicity Data (CMS, April)• SES on Quality and Resource Use (ASPE, Oct)
Oct 1, 2017CMS Issues Providers’ Performance Reports
Oct 1, 2018IRH/Us Start Reporting:• Standardized Patient Assessment Data
(SPAD)• Remaining 2 Quality Measures (Medication
Reconciliation, Patient Care Preferences)
Oct 2019ASPE Report on Impact of Risk Factors on Quality and Resource Measures
Est. Oct, 2021CMS Report Recommending PAC PPS Technical Prototype
Est. June 30, 2022MedPAC Report Recommending PAC PPS Technical Prototype
Oct 1, 2018• Provider Performance
Reports Made Public•CMS Matches Claims to
Patient Assessment Data
IMPACT Act of 2014: Timeline for IRH/Us and HHS
PR
OV
IDER
SH
HS, M
EDPA
C
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Chapter 3
Mandated Report:
Developing a Unified Payment System for Post
Acute Care
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MedPAC Report: Super Short Summary
• A PAC PPS Can Be Developed Now Using Administrative Data
• Once IMPACT Act Data Collected It Can Be Refined
• Based on a PAC Stay Not an Episode
• Redistributive
Waive Certain Regulatory Requirements
3 Hour Rule (IRF) 60% Rule (IRF)
Physician Visit Frequency 25 Day LOS (LTCH)
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MedPAC Report: Super Short Summary
• VBP and Readmissions To “Dampen FFS Incentive”
• Transition Policy
• Monitoring Policy: To Check on Stinting and Cherry Picking
• Patient Centered vs. Site Centered
• Third Party Manage
• Payment• IRF: – 12% LTCH: – 25%
• SNF: + 8%
• SNF Bias? What Has To Happen Next?COPYRIGHT 2016, AMRPA, WASHINGTON, DC 69
69COPYRIGHT 2016, AMRPA, WASHINGTON, DC
Recommends Moving Forward Now With a PAC PPS Based on
Administrative Data e.g. Claims + Other
Concerns About MedPAC Report
ICU+CCU Stay
No Functional Data
Diagnosis (MS-DRG)
Comorbidities
Age, Disability
Patient Severity
and Treatment
(APR-DRG)
Proxies for Impairment
and Cognitive
Status
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MedPAC September 8-9 Meeting
Session on Uniform Outcome Measures Under a Unified PAC Payment System
Looking at Potentially Avoidable Readmission Rates and MSBP
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2013 Data Used: PAC Stays 8.9
Million; 24, 903 Providers
EstimatedResource
Use (Nursing)
Amend Later to Include SPAD –
Historically Difficult
Payment Shift Away from Rehab
Therapy Unrelated to Patient
Care
Data Approach is Incomplete
Built on ICD-9 v. ICD-10
Concerns About MedPAC Report
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ADVERSE EVENTS IN
REHABILITATION
HOSPITALS:
NATIONAL INCIDENCE
AMONG
MEDICARE
BENEFICIARIES
July 2016
73
Bundled Payment Care Initiative (BPCI) Still Uses FFS Payment Model: Rehab Can Be Partner and Separately a Bundle Holder
Model 1
• Retrospective Acute Care Hospital Stay Only
• 32 Awardees Began April 2013
Model 2
• Retrospective Acute Care Hospital Stay plus Post-Acute Care
Model 3
• Retrospective Post-Acute Care Only
Model 4
• Prospective Acute Care Hospital Stay Only
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• Started in
August 2011
• Four Models
Currently Active
• Focus on
Episode
Payment and
Quality
Goal: Improve
Patient Care,
Lower CostsCovers 48 Clinical Episodes and 180 Anchor MS-DRGs
Source: CMS
75
FFS
HHS 1
FFS HaircutHHS 2
ACO/MSSP,
CJR, EPM
BPCI
HHS 3
IMPACT Act
New
Global or Population
Health
HHS 4
Alternative Payment ModelsPAC Payment Reform:
Anticipated Progression and HHS Perspective
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Patient Acute Care
Hospital
ACUTE REHAB HOSPITAL/UNIT
LONG TERM HOSPITAL
KEYHOME HEALTH
CARE HOMEOUTPATIENT
REHAB
OUTPATIENT REHAB
HOME HEALTHCARE
HOME
OUTPATIENT REHAB
HOME HEALTHCARE
HOME
OUTPATIENT REHAB
HOME HEALTHCARE
HOME
OUTPATIENT REHAB
HOME HEALTHCARE
ACUTE REHAB HOSPITAL/UNIT
HOME
OUTPATIENT REHAB
HOME HEALTHCARE
Nursing Home SNF
OUTPATIENT REHAB
HOME HEALTHCARE
Nursing Home SNF
HOME
Nursing Home SNF
LTC/ASSISTED LIVING
OUTPATIENT REHAB
HOME HEALTHCARE
Nursing Home SNF
HOME
Is It Still Accurate? Current Delivery System: Again
HOSPITAL SNF
LTC/ ASSISTED LIVING
Nursing Home SNF
LTC/ASSISTED LIVING
LTC/ASSISTED LIVING
ACUTE REHAB HOSPITAL/UNIT
Long Term Hospital
Hospital SNF
Long Term Hospital
ACUTE REHAB
Hospital SNF
Revised 5/14/10
Long Term Hospital
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MSSP/ACOs
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About 397 MSSP ACOs
19 Pioneer ACOs
CY 2015
Beneficiaries Covered in 2014:
• 5.6 Million in MSSP or Pioneers
• Exceed 10% of Medicare Population
• 30% Medicare Beneficiaries in Medicare Advantage
• So…
78
Comprehensive Care for Joint Replacement (CJR)Payment Model
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Episode of Care: 3 Days Prior, Acute Care Stays
Plus 90 Days Post Acute Hospital Stay
Mandatory Participation for ALL Acute Hospitals
in 67 Designated MSAs.
Acute and PAC Bundle for Lower Extremity Joint
Replacement for MS-DRGs 469 and 470
5 Year Program
IRFs May Be Collaborators
Two Sided Risk Starting in Year 2
Payment Keyed to Episode Target
Amount and Performance on Quality Metrics
Proposed Bundle for Cardiac Care;
Inclusion of Surgical Hip/Femur Fracture
Treatment (SHFFT) and Focus on Cardiac Rehab
• Structure Similar to CJR
• Episode Payment Models for Heart Attack and Bypass Surgeries‒98 MSAs Not Specified in NPRM
‒90 Days Post Acute Stay
‒Similar Model to CJR
‒5 Year Program
‒Two Sided Risk Starting in Year 2
‒MS-DRGs 280-282, 246-251, 231-236
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Proposed Bundle for Cardiac Care;
Inclusion of Surgical Hip/Femur Fracture
Treatment (SHFFT) and Focus on Cardiac
Rehab
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Expand CJR to Include Hip/Femur Fracture
Same 67 MSAs
Includes MS-DRGs 480-482
Cardiac Rehab
Incentive Payment
In 45 Non Compliance MSAs
In 45 Cardiac MSAs
81
Bundle Is Hospital Stay Plus
90 Days Post Discharge
Mirroring CJR
Down Side Risk Payment Starts In
Year Two Capped At 5%; In Year 5
Capped At 20%
Gainsharing Started In Year One (1), Capped At
Five Percent (5%); Maximum of 20% In
Years Four (4) and Five (5)
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New Proposed Bundle for Cardiac Care; Inclusion of Surgical Hip/Femur Fracture Treatment (SHFFT) and Focus on Cardiac Rehab
Will CMS Stop Here This Year?
Payment Based on Payment Related to Target Price and
Quality Performance
Performance
Year (PY)
Calendar
YearEPM Episodes Included in Performance Year
1 2017 EPM Episodes that start on or after July 1, 2017 and end on or before
December 31, 2017
2 2018 EPM Episodes that end from January 1, 2018 through December 31, 2018,
inclusive
3 2019 EPM Episodes that end from January 1, 2019 through December 31, 2019,
inclusive
4 2020 EPM Episodes that end from January 1, 2020 through December 31, 2020,
inclusive
5 2021 EPM Episodes that end from January 1, 2021 through December 31, 2021,
inclusive
Source: Medicare Program; Advancing Care Coordination through Episode Payment Models, (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the
Comprehensive Care for Joint Replacement Model (CJR) Proposed Rule, August 2, 2016 Federal Register.
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Table 5: Performance Years for EPMs
Payment Based on Payment Related to Target Price
and Quality Performance
Repayment Discount
Quality Score Reconciliation
Discount
Year 1 and
Quarter 1 of
Year 2
Quarters 2-4 of
Year 2 and Year 3
Years 4 & 5
Below
acceptable
N/A N/A 2.0% 3.0%
Acceptable 3.0% N/A 2.0% 3.0%
Good 2.0% N/A 1..0% 2.0%
Excellent 1.5% N/A 0.5% 1.5%
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Table 2: Discount Factor by Performance Year
Incentive Payments for Cardiac Rehabilitation•Includes 45 MSAs Where Cardiac Bundle Taking Place
•Includes 45 MSAs Where Cardiac Bundle Not Taking Place
•5 Year Program Also
•Incentive Payment of $25.00 For First 11 Services For Heart Attack and Bypass Surgery Patients
•After That, Payment Goes To $175 Per Service
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CMS New Payment Models, Including BPCI
• Bundle Is a Episode
• Payment Is Retroactive FFS Target Price Which Is a Reduction from
Historic Payment
• Creative Responses by All Providers and Great Opportunities
• Special Issues for IRFs
• Payment Also Based on Quality Performance – CJR, SHFFT, Cardiac
• Rewards and Penalties
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Implications for Rehabilitation Providers ?
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AMI
CAGB
Hip Fracture/
Femur Fracture
Cardiac Rehab
IMPACT Act: Development and Maintenance of Post-Acute Care Cross Setting Standardized Patient Assessment Data:
Data Element Specifications for Public Comment
• AMRPA Secured Expanded Comment Period
• Comment on SPAD Domains and Data Elements
Cognitive Function and Mental Status: 5 Elements
Medical Condition: Pain
Impairments: Hearing and Vision
Special Services
• NOTE: Data Collected from These Elements and the Quality Resource Measures Will Be Used in Analyses Leading to the Third Step of the IMPACT Act – the PAC PPS
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IMPACT Act: Development and Maintenance of Post-Acute Care Cross Setting Standardized Patient Assessment Data:
Data Element Specifications for Public Comment
• At The Same Time: Field Testing Additional Elements for Feasibility – First Wave
• Cognitive
• Mood
• Patient Preference
• Other
• 8 Providers Over 8 Weeks
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"Toto, I don't think we're in Kansas anymore"
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QUESTIONS & ANSWERS?
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Carolyn C. Zollar M.A. J.D.
Executive Vice President for Government
Relations and Policy Development
AMRPA
1710 N Street N.W.
Washington, D. C. 20036
Phone: 202-223-1920
Toll-free: 888-346-4624
Fax: 202-223-1925
Email: czollar@amrpa.org
Website: www.amrpa.org
APPENDIX
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Examples of Measure Specifications
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Inpatient Rehabilitation Facilities Domain NQF
Measure ID
Measure Title Reporting and Payment
Timeline
Function #2633*
Change in Self-Care Score for Medical Rehabilitation Patients
Initial Reporting
October
– December 2016
for fiscal year (FY)
2018 payment
adjustment
followed by CY
reporting for that
of subsequent
FYs
Measure Description: This measure estimates the risk-adjusted mean change
in self-care score between admission and discharge for Inpatient
Rehabilitation Facility (IRF) Medicare patients.
Numerator Statement: The measure does not have a simple form for the
numerator and denominator. This measure estimates the risk-adjusted change
in self-care score between admission and discharge among Inpatient
Rehabilitation Facility (IRF) Medicare patients age 21 or older. The change in
self-care score is calculated as the difference between the discharge self-care
score and the admission self-care score.
Denominator Statement: Inpatient Rehabilitation Facility patients included in
this measure are at least 21 years of age, Medicare beneficiaries, are not
independent on all of the self-care activities at the time of admission, and
have complete stays
Examples of Measure Specifications
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Inpatient Rehabilitation Facilities Domain NQF Measure
ID
Measure Title Reporting and Payment
Timeline
Function #2635* Discharge Self-Care Score for Medical
Rehabilitation Patients Initial Reporting October
– December 2016 for fiscal
year (FY) 2018 payment
adjustment followed by CY
reporting for that of
subsequent FYs
Measure Description:
This measure estimates the percentage of IRF patients
who meet or exceed an expected discharge self-care score.
Numerator Statement: The numerator is the number of
patients in an IRF with a discharge score that is equal to
or higher than the calculated expected discharge score.
Denominator Statement: Inpatient Rehabilitation
Facility patients included in this measure are at least 21
years of age,
Medicare beneficiaries, and are not independent on all of
the self-care activities at the time of admission, and have
complete stays.
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Table 7—Quality Measures Previously Finalized for and Currently Used in the IRF Quality
Reporting Program
Measure title Final ruleData collection
start date
Annual payment
determination:
initial and subsequent
APU years
National Healthcare Safety Network (NHSN)
Catheter-Associated Urinary Tract Infection
(CAUTI) Outcome Measure (NQF #0138)
Adopted an application of the
measure in FY 2012 IRF PPS
Final Rule (76 FR 47874 through
47886)
October 1, 2012FY 2014 and
subsequent years.
Adopted the NQF-endorsed
version and expanded measure
(with standardized infection
ratio) in CY 2013 OPPS/ASC
Final Rule (77 FR 68504 through
68505)
January 1, 2013FY 2015 and
subsequent years.
Percent of Residents or Patients with Pressure Ulcers
That Are New or Worsened (Short Stay) (NQF
#0678)
Adopted application of measure
in FY 2012 IRF PPS final rule
(76 FR 47876 through 47878)
October 1, 2012FY 2014 and
subsequent years.
Source: FY 2017 IRF PPS NPRM, April 29, 2016
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Table 7—Quality Measures Previously Finalized for and Currently Used in the IRF
Quality Reporting Program
Measure title Final ruleData collection
start date
Annual payment
determination: initial and
subsequent APU years
Percent of Residents or Patients with Pressure
Ulcers That Are New or Worsened (Short
Stay) (NQF #0678) Cont’d
Adopted a non-risk-adjusted
application of the NQF-
endorsed version in CY 2013
OPPS/ASC Final Rule (77 FR
68500 through 68507)
January 1, 2013FY 2015 and subsequent
years.
Adopted the risk adjusted,
NQF-endorsed version in FY
2014 IRF PPS Final Rule (78
FR 47911 through 47912)
October 1, 2014FY 2017 and subsequent
years.
Adopted in the FY 2016 IRF
PPS final rule (80 FR 47089
through 47096) to fulfill
IMPACT Act requirements
October 1, 2015FY 2018 and subsequent
years.
Source: FY 2017 IRF PPS NPRM, April 29, 2016
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Table 7—Quality Measures Previously Finalized for and Currently Used in the IRF Quality
Reporting Program
Measure title Final ruleData collection
start date
Annual payment
determination: initial and
subsequent APU years
Percent of Residents or
Patients Who Were Assessed
and Appropriately Given the
Seasonal Influenza Vaccine
(Short Stay) (NQF #0680)
Adopted in FY 2014 IRF PPS final rule (78
FR 47906 through 47911)October 1, 2014 FY 2017 and subsequent years.
Influenza Vaccination Coverage
among Healthcare Personnel
(NQF #0431)
Adopted in FY 2014 IRF PPS final rule (78
FR 47905 through 47906)October 1, 2014 FY 2016 and subsequent years.
All-Cause Unplanned
Readmission Measure for 30
Days Post Discharge from
Inpatient Rehabilitation
Facilities (NQF #2502)
Adopted in FY 2014 IRF PPS final rule (78
FR 47906 through 47910)N/A FY 2017 and subsequent years.
Adopted the NQF-endorsed version in FY
2016 IRF PPS final rule (80 FR 47087
through 47089)
N/A FY 2018 and subsequent years.
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Table 7—Quality Measures Previously Finalized for and Currently Used in the IRF Quality
Reporting Program
Measure title Final ruleData collection
start date
Annual payment
determination: initial and
subsequent APU years
National Healthcare Safety Network
(NHSN) Facility-Wide Inpatient Hospital-
Onset Methicillin-Resistant Staphylococcus
aureus (MRSA) Bacteremia Outcome
Measure (NQF #1716)
Adopted in the FY 2015 IRF PPS
final rule (79 FR 45911 through
45913)
January 1, 2015 FY 2017 and subsequent years.
National Healthcare Safety Network
(NHSN) Facility-Wide Inpatient Hospital-
Onset Clostridium difficile Infection (CDI)
Outcome Measure (NQF #1717)
Adopted in the FY 2015 IRF PPS
final rule (79 FR 45913 through
45914)
January 1, 2015 FY 2017 and subsequent years.
Application of Percent of Residents
Experiencing One or More Falls with Major
Injury (Long Stay) (NQF #0674).
Adopted an application of the
measure in FY 2016 IRF PPS
Final Rule (80 FR 47096 through
47100).
October 1, 2016 FY 2018 and subsequent years.
Source: FY 2017 IRF PPS NPRM, April 29, 2016
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Table 7—Quality Measures Previously Finalized for and Currently Used in the IRF Quality
Reporting Program
Measure title Final ruleData collection
start date
Annual payment determination:
initial and subsequent APU years
Application of Percent of Long-
Term Care Hospital Patients
with an Admission and
Discharge Functional
Assessment and Care Plan That
Addresses Function (NQF
#2631)
Adopted an application of the measure in FY
2016 IRF PPS Final Rule (80 FR 47100
through 47111).
October 1, 2016 FY 2018 and subsequent years.
IRF Functional Outcome
Measure: Change in Self-Care
for Medical Rehabilitation
Patients (NQF #2633)*
Adopted in the FY 2016 IRF PPS final rule
(80 FR 47111 through 47117)October 1, 2016 FY 2018 and subsequent years.
IRF Functional outcome
Measure: Change in Mobility
Score for Medical Rehabilitation
(NQF #2634) *
Adopted in the FY 2016 IRF PPS final rule
(80 FR 47117 through 47118)October 1, 2016 FY 2018 and subsequent years.
Source: FY 2017 IRF PPS NPRM, April 29, 2016
* These measures were under review at NQF when they were finalized for use in the IRF QRP. These measures are now NQF-endorsed
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Table 7—Quality Measures Previously Finalized for and Currently Used in the IRF Quality
Reporting Program
Measure title Final ruleData collection
start date
Annual payment determination:
initial and subsequent APU years
IRF Functional Outcome
Measure: Discharge Self-Care
Score for Medical
Rehabilitation Patients (NQF
#2635)
Adopted in the FY 2016 IRF PPS final rule
(80 FR 47118 through 47119)October 1, 2016 FY 2018 and subsequent years.
IRF Functional Outcome
Measure: Discharge Mobility
Score for Medical
Rehabilitation Patients (NQF
#2636)
Adopted in the FY 2016 IRF PPS final rule
(80 FR 47119 through 47120)October 1, 2016 FY 2018 and subsequent years.
Source: FY 2017 IRF PPS NPRM, April 29, 2016
MedPAC: Summary of Findings for a PAC PPS
Design features Discussion
Common unit of service (the stay)
A common unit avoids the incentive to furnish
unnecessary days or visits, but the incentive to
discharge patients prematurely needs to be
monitored.
Common risk adjustment using administrative data on
patient characteristics
Administrative data can establish accurate payments
for most type of stays. Payments are tied to patient
characteristics and avoid the incentive to furnish
unnecessary rehabilitation care as a way to generate
payments. In the future, functional assessment data
could be added to the risk adjustment.
Two payment models to reflect differences in benefits
across settings
One model establishes payments for routine and
therapy care; a separate model establishes payments
for non-therapy ancillary care (such as drugs).
Alignment of payments for home health stays
Without aligning payments to costs of home health
stays, care in this setting would be considerably
overpaid.
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Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC
Empirically based payment adjusters applied to
all settings
Setting-specific adjusters would reinforce
adverse incentives under existing separate
payment systems.
High-cost outlier policy
A higher-cost outlier policy helps ensure access
to care for high-cost patients while protecting
providers that treat them from large losses.
Short-stay outlier policy
A short-stay outlier policy protects the program
form large overpayments and discourages
premature discharges.
No broad rural adjusters
Results do not support a broad rural or frontier
adjustment. However, the Secretary should
evaluate the need for an adjustment for low-
volume, isolated providers.
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MedPAC: Summary of Findings for a PAC PPS
Design features Discussion
Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC
No IRF teaching adjustment
Results do not support an IRF adjustment.
Combined with an outlier policy, risk
adjustment could establish accurate
payments.
More data regarding an adjustment for
providers treating high shares of low-income
patients
Our examination found a possible need for
an adjustment for IRFs with the highest
shares of low-income patients; we lacked
the data to examine providers in settings
other than IRFs. The Secretary should
evaluate the need for such adjustment
across all PAC settings.
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Design features Discussion
MedPAC: Summary of Findings for a PAC PPS
Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC
Impact of changes
Payment shifts among types and stays
Changes increase payments for medical and
most medically complex stays and reduce
payments for stays with high rehabilitation
services unrelated to patient care needs.
Payment shifts among providers and
settings
Changes in payments reflect a provider’s
mix of the types of stays it treats, its
therapy practices, and its existing cost
structures.
More information profitability across types
of stays
Change dampen incentive to selectively
admit certain type of patients.
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MedPAC: Summary of Findings for a PAC PPS
Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC
Conforming regulatory requirements
Near term: Waiving of select regulatory
requirements
The Secretary should evaluate which setting-
specific regulatory requirements should be
waived when the PPS is implemented. Waiving
regulatory requirements would give providers
flexibility to offer a broad mix of PAC services
and would allow providers to begin to change
their cost structures to adapt to a new payment
system.
Longer term: “Core” set of requirements for all
PAC providers and specific requirements to treat
patients with specialized care needs
Core and specific requirements move toward
uniform requirements across settings and provide
flexibility to treat specialized patient care needs.
Standardized beneficiary cost sharing for PAC Standardized cost sharing reduces the influence
of financial considerations for patients choosing
where to receive PAC.
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Note: PAC (Post-Acute Care), PPS (Prospective Payment System), IRF (Inpatient Rehabilitation Facility)
MedPAC: Summary of Findings for a PAC PPS
Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC
Implementation issues
Level of payments Some amount of rebasing is necessary to
align payments and costs.
Transition period Transition period gives providers time to
adjust their cost structures. Providers could
be allowed to skip the transition and elect to
be paid under the new PAC PPS. An initial
PAC PPS could have implemented sooner
using administrative data for risk
adjustment, with future refinements to the
risk adjustment implemented once patient
assessment data are available.
Authority for Secretary to periodically revise
and rebase payments
Refinements will maintain alignment of
payments to costs.
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MedPAC: Summary of Findings for a PAC PPS
Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC
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Comparison policies
Readmission policy Readmissions policy counters the
incentive to furnish poor-quality care
that might result in hospital
readmissions.
Value based purchasing that includes a
resource a resource use measure
Value-based purchasing ties payments
to outcomes and helps prevent
unnecessary service provision, including
serial PAC stays.
MedPAC: Summary of Findings for a PAC PPS
Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC
Monitoring
Monitoring of quality, volume of PAC
stays, and selective admissions
Measures would detect inappropriate
provider responses, including stinting on
care, generating unnecessary PAC stays,
delaying care, and patient selection
(which could indicate a misalignment of
payments to costs).
Evaluate of the adequacy of Medicare
payments
Evaluation signals whether payments are
adequate to cover the costs of efficient
providers in treating beneficiaries,
thereby helping to ensure appropriate
access to care.
Note: PAC (Post-Acute Care), PPS (Prospective Payment System), IRF (Inpatient Rehabilitation Facility)
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MedPAC: Summary of Findings for a PAC PPS
Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC
Process for Requesting CMS Review of Preview Report Data
•Requests for CMS review of your provider Preview Report data, if believed to be inaccurate, must be submitted during the 30-day review period, which begins on the day the provider preview reports are issued in the IRF CASPER folders.
•IRFs are required to submit their request to CMS via email with the subject line: “[Provider/Facility Name] Public Reporting Request for Review of Data,” and include the CMS Certification Number (CCN) (e.g., Saint Mary’s Public Reporting Request for Review of Data, XXXXXX). The request must be sent to the following email address: LTCHPRquestions@cms.hhs.gov for LTCHs and IRFPRquestions@cms.hhs.gov for IRFs.
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Process for Requesting CMS Review of Preview Report Data
•The Email Request Must Include The Following Information: CMS Certification Number (CCN).
Business Name.
Business Address.
CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address.
Information supporting the provider’s belief that the data contained within the Provider Preview Report is erroneous (numerator, denominator, or quality measure result), including, but not limited to, the following:
◦ Quality measures affected, and aspects of quality measures affected (numerator, denominator, or other quality measure result).
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Process for Requesting CMS Review of Preview Report Data
•CMS Will Review All Requests and Provide a Response With a Decision Via Email.
•Data That CMS Agrees To Correct Will Be Reflected With the Subsequent Quarterly Release of Quality Data on IRF Compare.
•Sending Preview Reports Sept 1 On Casper System.
•Late Fall 2016 for Go Live on Compare site.
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Quality Measure Reports
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• Certification And Survey Provider Enhanced Reports (CASPER) QM Facility-Level and Patient-Level Reports:
Confidential Feedback Reports.
Contain quality measure information at the facility-and patient-level for a single reporting period.
Providers are able to select the data collection end date and obtain aggregate performance data.
Reports are available on a monthly basis and can be used to determine any data submission errors that may affect quality measure data.
Review and Correct Reports
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• Confidential Feedback Reports.
Contains facility-level quality measure data.
Displays assessment-based quality measure data only.
• Providers are able to obtain facility-level performance for quarterly and cumulative performance rates.
• As time advances, the earliest quarter is dropped, and the most recent quarter added.
• IMPACT Act: https://www.govtrack.us/congress/bills/113/hr4994
• CMS IMPACT Act Website:
◦https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/Spotlights-and-Announcements-.html
• Comments Can Be Submitted to:
◦PACQualityInitiative@cms.hhs.gov
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