who are we and where is medical rehabilitation during a time of …€¦ · annual increase. •...

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

[email protected]

COPYRIGHT 2016, AMRPA, WASHINGTON, DC 2

State of the Field

Congressional Action

State of Payment and Quality Measures

Audit Agony

Managed Care

New Twists


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


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



• 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



• Lame Duck Session Expected

• Bill Revisions

Withhold 5% vs 8%

No Cross PAC Comparison

Repeal FY 2018 1% Market Basket Reduction



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

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/index.html


Continued Death By a Thousand Slashes


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


*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


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


$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


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html

CMS Reevaluates Comorbidities Under IRF PPS


• 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


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


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


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


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”


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



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?


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


• 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:


Instruments/IRF-Quality-Reporting/Downloads/IRF-LTCH-Public-Reporting-

Webinar-8-23-16.PDF

IRF Quality Measures and Reporting


Illinois

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Training.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/IRF-LTCH-Public-Reporting-Webinar-8-23-16.PDF

• 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


Illinois

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRFPAI.html

• 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 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



IMPACT Act Three Phases of Quality and Resource Use Measure Development and Implementation:

Already Published in FY 2016 and FY 2017 Final Rules


• 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


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


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: [email protected]

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Public-Reporting.html

mailto:[email protected]

FY 2017 Final Rule Establishes Data Review and Public Reporting Policies per the IMPACT Act


Process for Claims Based Data

• Calculated Annually

• Available Annually

• Preview Reports Are for Feedback But Not Review and Correction


• 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


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.


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.


Provider Preview Reports


• 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.



• 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


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: [email protected]. or [email protected].

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.




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: [email protected]

• CMS August 23 Webinar: Quality Reporting Program Provider Training


Instruments/IRF-Quality-Reporting/Downloads/IRF-LTCH-Public-Reporting-

Webinar-8-23-16.PDF


https://www.qtso.com/IRFtrain.html

https://www.qtso.com/IRFtrain.html


https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/IRF-LTCH-Public-Reporting-Webinar-8-23-16.PDF

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


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


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 [email protected]

• 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)



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


47

CERT

PSC

MAC

ZPIC

RAs and MACs: WILL THIS TORTURE EVER END?

UPIC

RA

MICSMERC


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


https://www.dcsrac.com/IssuesUnderReview.aspx

https://racb.cgi.com/Issues.aspx

http://www.connolly.com/healthcare/pages/ApprovedIssues.aspx

https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx

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”


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


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


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)


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



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)



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


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


https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/TherapyCap.html

https://strategichs.com/smrc/project-y4p0430-macra-outpatient-rehabilitation-therapy-cap/

https://strategichs.com/2014WP/wp-content/uploads/2016/08/wY4P0430MACRAADRLtrPUBWEB071816f.pdf

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



Managed Care &

Rehabilitation


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


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


• 46% of These Events Were Preventable

• Findings for Acute Care and SNFs

Newest Twists


Chubby Checker


(ACT)


FFS

Quality

ACA

Payment

Reform

APM

Shift Risk

Bundling

Episodes

Population

Based

PaymentIMPACT ACT

Healthcare Environment:

Changes in Medical Rehabilitation

Value

Global Budgets


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

Copyright 2016, AMRPA, Washington, DC 66

Chapter 3

Mandated Report:

Developing a Unified Payment System for Post

Acute Care


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)



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


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


MedPAC September 8-9 Meeting

Session on Uniform Outcome Measures Under a Unified PAC Payment System

Looking at Potentially Avoidable Readmission Rates and MSBP


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


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


• 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

COPYRIGHT 2016, AMRPA., WASHINGTON, DC76

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


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


Long Term Hospital

Hospital SNF

Long Term Hospital

ACUTE REHAB

Hospital SNF

Revised 5/14/10

Long Term Hospital


MSSP/ACOs


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


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

COPYRIGHT 2016, AMRPA, WASHINGTON, DC 80 80

Proposed Bundle for Cardiac Care;

Inclusion of Surgical Hip/Femur Fracture

Treatment (SHFFT) and Focus on Cardiac

Rehab


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)


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


inclusive


inclusive


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.


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%


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


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


Implications for Rehabilitation Providers ?


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


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



"Toto, I don't think we're in Kansas anymore"


QUESTIONS & ANSWERS?


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: [email protected]

Website: www.amrpa.org

APPENDIX


Examples of Measure Specifications


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


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.


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


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

https://www.federalregister.gov/citation/76-FR-47874




Table 7—Quality Measures Previously Finalized for and Currently Used in the IRF

Quality Reporting Program


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.







Reporting Program


start date

Annual payment



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)


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)


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.







Reporting Program


start date

Annual payment



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


47100).

October 1, 2016 FY 2018 and subsequent years.






Reporting Program


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) *




* These measures were under review at NQF when they were finalized for use in the IRF QRP. These measures are now NQF-endorsed





Reporting Program


start date

Annual payment determination:

initial and subsequent APU years


Measure: Discharge Self-Care

Score for Medical

Rehabilitation Patients (NQF

#2635)




Measure: Discharge Mobility

Score for Medical

Rehabilitation Patients (NQF

#2636)






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.


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.





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.





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.




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.


Note: PAC (Post-Acute Care), PPS (Prospective Payment System), IRF (Inpatient Rehabilitation Facility)



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.





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.



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)




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: [email protected] for LTCHs and [email protected] for IRFs.





•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).



•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.


Quality Measure Reports


• 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


• 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:

◦[email protected]


who are we and where is medical rehabilitation during a time of …€¦ · annual increase. •...

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