The IRF PPS FY 2017 Final Rule: What It Portends for Our Future

The IRF PPS FY 2017 Final Rule: What It Portends for Our Future Presenter: Carolyn C. Zollar, MA, J.D. Executive Vice President of Government Relations and Policy Development czollar@amrpa.org AMRPA Webinar Wednesday, August 17, 2016 1:00-2:30 p.m. ET COPYRIGHT 2016, AMRPA, WASHINGTON, DC 1

We Will Discuss FY 2017 IRF PPS Final Rule Payment Changes Why It Is Important To Keep an Eye on the IRF PPS (and all PPSs) for the Future FY 2017 IRF PPS Final Rule Changes to the Quality Reporting Program and IMPACT Act Measures Implementation Other QRP Changes Non Compliance Letters Newest Events MedPAC Report OIG Report Proposed Cardiac Bundling Program and CJR Changes, etc. IMPACT Act SPAD COPYRIGHT 2016, AMRPA, WASHINGTON, DC 2

Type of 1996 1998 2000 2002 2004 2006 2008 2010 2012 2013 2014 2015 2016 Provider State of the Field: Medicare Participating Post-Acute Care Providers as of 2016 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 Nursing Facility (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 12,318 Health 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 (Hospital & 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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 3

State of The Field Inpatient 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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 4

FY 2017 Medicare Prospective Payment Systems Rules Status * All dates are as of publication in the Federal Register* 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 April 27, 2016 MS-LTC- DRG PPS August 22, 2016 Skilled Nursing Facilities 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 Copyright 2016, AMRPA, Washington, DC 8

FY 2017 IRF PPS Final Rule Snapshot Standard Payment Rate Outlier Threshold Labor Share 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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 11

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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 12

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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 13

CMG Weights, Lengths of Stay and Comorbidities Case Mix Group Weight Updates with FY 2015 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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 14

Difference Between Medicare Payment and Provider Cost for FY 2017 Based on FY 2017 IRF PPS Final Rule (includes outlier payments) OR WA ID MT WY ND SD MN WI MI NY ME VT NH MA CT RI CA NV UT CO NE KS IA MO IL IN KY OH WV PA MD VA NJ DE AZ NM OK AR TN NC SC AK MS AL GA TX LA HI FL Payment is lower than cost Payment is higher than cost Changes from 2016 to 2017 MO, MS, OH, NC, SD, MI None COPYRIGHT 2016, AMRPA, WASHINGTON, DC Source: CMS FY 2017 IRF PPS Final Rule Rate Setting File AMRPA, Washington, DC, 2016 15

CMS Rate Setting Files 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 *2016 to date All payments include outliers. Sources: FYs 2015-2017 Final Rate Setting Files, CMS; erehabdata COPYRIGHT 2016, AMRPA, WASHINGTON, DC 16

How To Report IRF QRP Measure All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (NQF #2502) NHSN CAUTI Outcome Measure NQF #0138 Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431) NHSN Facility-Wide Inpatient Hospital-Onset MRSA Bacteremia Outcome Measure (NQF #1716) NHSN Facility-Wide Inpatient Hospital-Onset CDI Outcome Measure (NQF #1717) How Collected Claims NHSN NHSN NHSN NHSN NHSN COPYRIGHT 2016, AMRPA, WASHINGTON, DC 18

Measure How To Report IRF QRP Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay) NQF #0678 Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674) Application of Percent of Long- Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631) IRF Functional Outcome Measure: Change in Self- Care for Medical Rehabilitation Patients (NQF #2633)* IRF Functional outcome Measure: Change in Mobility Score for Medical Rehabilitation (NQF #2634)* IRF Functional Outcome Measure: Discharge Self- Care Score for Medical Rehabilitation Patients (NQF #2635) IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636) How Collected IRF PAI IRF PAI IRF PAI IRF PAI IRF PAI IRF PAI IRF PAI * These measures were under review at NQF when they were finalized for use in the IRF QRP. These measures are now NQF-endorsed. COPYRIGHT 2016, AMRPA, WASHINGTON, DC 19

How To Report IRF QRP Measures 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 How Collected Claims Based Claims Based Claims Based Claims Based IRF PAI October 1, 2018 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 20

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). IRF Quality Measures 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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 21

IRF Quality Measures FY 2016 IRF PPS Final Rule 8 Measures (6 New Measures) 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 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 22

IRF Quality Measures FY 2017 IRF PPS Final Rule 5 New Measures 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, 2015) COPYRIGHT 2016, AMRPA, WASHINGTON, DC 23

IRF Quality Measures CMS Held Two Training Sessions to Date Intercepted Falls An Issue Illinois Materials Available https://www.cms.gov/medicare/quality-initiatives-patient- Assessment-Instruments/IRF-Quality-Reporting/Training.html COPYRIGHT 2016, AMRPA, WASHINGTON, DC 24

FY 2017 Final Rule Establishes Data Review and Public Reporting Policies Process for IRF PAI Reported Data CMS Will Provide Feedback Reports After 4.5 Months Correction Period Ends 30 Days to Review and Correct Data Process for Claims Based Data Process for Claims Based Data Calculated Annually Available Annually Preview Reports Are for Feedback But Not Review and Correction COPYRIGHT 2016, AMRPA, WASHINGTON, DC 25

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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 26

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). COPYRIGHT 2016, AMRPA, WASHINGTON, DC 27

FY 2016 Rule Mentioned Three Measures for Public Display 1. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened(Short-Stay) (NQF #0678) 2. NHSN CAUTI Outcome Measure (NQF #0138) 3. All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From IRFs (NQF #2502) CMS Vague About Posting Date May Use Hospital Compare Approach COPYRIGHT 2016, AMRPA, WASHINGTON, DC 28

Letters Were Sent July 20 CMS Issues Non Compliance Letters for FY 2017 Payment 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) COPYRIGHT 2016, AMRPA, WASHINGTON, DC 29

ICD-10 CM Issues Codes Pertaining to Brain Injury Not Included In Presumptive Compliance Methodology Affects IGC Codes 2.21 and 2.22 CMS Made No Changes AMRPA Continuing to Object COPYRIGHT 2016, AMRPA, WASHINGTON, DC 30 30

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 Says It Will Let Appeals Process Work As Designed It Will Take 10 Years to Clear This Backlog COPYRIGHT 2016, CAROLYN C. ZOLLAR, J.D., WASHINGTON, DC 31

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) COPYRIGHT 2016, AMRPA, WASHINGTON, DC 35 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 35

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 36 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 36

Concerns About MedPAC Report Recommends Moving Forward Now With a PAC PPS Based on Administrative Data e.g. Claims + Other ICU+C CU Stay Diagnosis (MS-DRG) Age, Disability Proxies for Impairment and Cognitive Status No Function al Data Comorbidities Patient Severity and Treatment (APR- DRG) COPYRIGHT 2016, AMRPA, WASHINGTON, DC 37

Concerns About MedPAC Report 2013 Data Used: PAC Stays 8.9 Million; 24, 903 Providers Estimated Resource 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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 38

ADVERSE EVENTS IN REHABILITATION HOSPITALS: NATIONAL INCIDENCE AMONG MEDICARE BENEFICIARIES July 2016 39

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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 40

OIG Issues Trend Report on Adverse Events: This One Focuses on Rehab Hospitals 46% of These Events Were Preventable Findings for Acute Care and SNFs Adverse Events IPPS 27% 44% SNFs 33% 59% IRFs 29% 46% Methodology: Global Trigger Tool Preventable COPYRIGHT 2016, AMRPA, WASHINGTON, DC 41

PAC Payment Reform: Anticipated Progression and HHS Perspective FFS HHS 1 FFS Haircut HHS 2 ACO/MSSP, CJR, EPM BPCI HHS 3 IMPACT Act New Global or Population Health HHS 4 COPYRIGHT 2016, AMRPA., WASHINGTON, DC 43

Bundled Payment Care Initiative (BPCI) Still Uses FFS Payment Model: Rehab Can Be Partner and Separately a Bundle Holder Started in August 2011 Four Models Currently Active Participants Announced January 2013 Goal: Improve Patient Care, Lower Costs 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 100 Participants with >400 Partners, Began October 2013 Covers 48 Clinical Episodes and 180 Anchor MS-DRGs Participants Announced January 2013 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 44

Comprehensive Care for Joint Replacement (CJR) Payment Model Acute and PAC Bundle for Lower Extremity Joint Replacement for MS- DRGs 469 and 470 Mandatory Participation for ALL Acute Hospitals in 67 Designated MSAs. IRFs May Be Collaborators Episode of Care: 3 Days Prior, Acute Care Stays Plus 90 Days Post Acute Hospital Stay COPYRIGHT 2016, AMRPA, WASHINGTON, DC 45

New Proposed Bundle for Cardiac Care; Inclusion of Surgical Hip/Femur Fracture Treatment (SHFFT) and Focus on Cardiac Rehab Episode Payment Models for Heart Attack and Bypass Surgeries 98 MSAs 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 46

New 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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 47

New Proposed Bundle for Cardiac Care; Inclusion of Surgical Hip/Femur Fracture Treatment (SHFFT) and Focus on Cardiac Rehab 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) Will CMS Stop Here This Year? COPYRIGHT 2016, AMRPA, WASHINGTON, DC 48

Payment Based on Payment Related to Target Price and Quality Performance Performance Year (PY) Calendar Year Table 5: Performance Years for EPMs EPM 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. COPYRIGHT 2016, AMRPA, WASHINGTON, DC 49

Payment Based on Payment Related to Target Price and Quality Performance Quality Score Below acceptable Table 2: Discount Factor by Performance Year Reconciliation Discount Year 1 and Quarter 1 of Year 2 Repayment Discount Quarters 2-4 of Year 2 and Year 3 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% Years 4 & 5 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 50

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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 51

Development and Maintenance of Post-Acute Care Cross Setting Standardized Patient Assessment Data: Data Element Specifications for Public Comment Request for Comments by August 26, Announced August 15 Not Adequate Time Comment on SPAD Data Elements Cognitive Function and Mental Status Medical Condition: Pain Impairments; Hearing and Vision Special Services Data Collected from These Elements and the Quality Resource Measures Will Be Used in Analyses Leading to PAC PPS COPYRIGHT 2016, AMRPA, WASHINGTON, DC 53

Carolyn C. Zollar M.A. J.D. Executive Vice President for Government Relations & 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 55

Domain NQF Measure ID Function #2633* Examples of Specifications Inpatient Rehabilitation Facilities Measure Title Change in Self-Care Score for Medical Rehabilitation Patients 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 Reporting and Payment Timeline Initial Reporting October December 2016 for fiscal year (FY) 2018 payment adjustment followed by CY reporting for that of subsequent FYs COPYRIGHT 2016, AMRPA, WASHINGTON, DC 57

Examples of Specifications Inpatient Rehabilitation Facilities Domain NQF Measure ID Measure Title Function #2635* Discharge Self-Care Score for Medical Rehabilitation Patients 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. Reporting and Payment Timeline Initial Reporting October December 2016 for fiscal year (FY) 2018 payment adjustment followed by CY reporting for that of subsequent FYs COPYRIGHT 2016, AMRPA, WASHINGTON, DC 58

Table 7 Quality Measures Previously Finalized for and Currently Used in the IRF Quality Reporting Program Measure title Final rule Data 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) Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) Source: FY 2017 IRF PPS NPRM, April 29, 2016 Adopted an application of the measure in FY 2012 IRF PPS Final Rule (76 FR 47874 through 47886) Adopted the NQF-endorsed version and expanded measure (with standardized infection ratio) in CY 2013 OPPS/ASC Final Rule (77 FR 68504 through 68505) Adopted application of measure in FY 2012 IRF PPS final rule (76 FR 47876 through 47878) October 1, 2012 January 1, 2013 October 1, 2012 FY 2014 and subsequent years. FY 2015 and subsequent years. FY 2014 and subsequent years. COPYRIGHT 2016, AMRPA, WASHINGTON, DC 59

Table 7 Quality Measures Previously Finalized for and Currently Used in the IRF Quality Reporting Program Measure title Final rule Data 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 NQFendorsed version in CY 2013 OPPS/ASC Final Rule (77 FR 68500 through 68507) Adopted the risk adjusted, NQF-endorsed version in FY 2014 IRF PPS Final Rule (78 FR 47911 through 47912) Adopted in the FY 2016 IRF PPS final rule (80 FR 47089 through 47096) to fulfill IMPACT Act requirements January 1, 2013 October 1, 2014 October 1, 2015 FY 2015 and subsequent years. FY 2017 and subsequent years. FY 2018 and subsequent years. Source: FY 2017 IRF PPS NPRM, April 29, 2016 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 60

Table 7 Quality Measures Previously Finalized for and Currently Used in the IRF Quality Reporting Program Measure title Final rule Data 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) Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431) 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 47911) Adopted in FY 2014 IRF PPS final rule (78 FR 47905 through 47906) Adopted in FY 2014 IRF PPS final rule (78 FR 47906 through 47910) Adopted the NQF-endorsed version in FY 2016 IRF PPS final rule (80 FR 47087 through 47089) COPYRIGHT 2016, AMRPA, WASHINGTON, DC October 1, 2014 October 1, 2014 N/A N/A FY 2017 and subsequent years. FY 2016 and subsequent years. FY 2017 and subsequent years. FY 2018 and subsequent years. 61

Table 7 Quality Measures Previously Finalized for and Currently Used in the IRF Quality Reporting Program Measure title Final rule Data 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) 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 45911 through 45913) Adopted in the FY 2015 IRF PPS final rule (79 FR 45913 through 45914) January 1, 2015 January 1, 2015 FY 2017 and subsequent years. 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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 62

Table 7 Quality Measures Previously Finalized for and Currently Used in the IRF Quality Reporting Program Measure title Application of Percent of Long- Term Care Hospital Patients with an Admission and Discharge Functional Assessment and Care Plan That Addresses Function (NQF #2631) IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients (NQF #2633)* IRF Functional outcome Measure: Change in Mobility Score for Medical Rehabilitation (NQF #2634) * Final rule Adopted an application of the measure in FY 2016 IRF PPS Final Rule (80 FR 47100 through 47111). Adopted in the FY 2016 IRF PPS final rule (80 FR 47111 through 47117) Adopted in the FY 2016 IRF PPS final rule (80 FR 47117 through 47118) Data collection start date Annual payment determination: initial and subsequent APU years October 1, 2016 FY 2018 and subsequent years. October 1, 2016 FY 2018 and subsequent years. October 1, 2016 FY 2018 and subsequent years. * These measures were under review at NQF when they were finalized for use in the IRF QRP. These measures are now NQF-endorsed Source: FY 2017 IRF PPS NPRM, April 29, 2016 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 63

Table 7 Quality Measures Previously Finalized for and Currently Used in the IRF Quality Reporting Program Measure title Final rule Data 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) IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636) Adopted in the FY 2016 IRF PPS final rule (80 FR 47118 through 47119) Adopted in the FY 2016 IRF PPS final rule (80 FR 47119 through 47120) October 1, 2016 FY 2018 and subsequent years. October 1, 2016 FY 2018 and subsequent years. Source: FY 2017 IRF PPS NPRM, April 29, 2016 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 64

MedPAC: Summary of Findings for a PAC PPS Design features Common unit of service (the stay) Common risk adjustment using administrative data on patient characteristics Two payment models to reflect differences in benefits across settings Alignment of payments for home health stays Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC Discussion A common unit avoids the incentive to furnish unnecessary days or visits, but the incentive to discharge patients prematurely needs to be monitored. 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. One model establishes payments for routine and therapy care; a separate model establishes payments for non-therapy ancillary care (such as drugs). Without aligning payments to costs of home health stays, care in this setting would be considerably overpaid. COPYRIGHT 2016, AMRPA, WASHINGTON, DC 65

Design features Empirically based payment adjusters applied to all settings High-cost outlier policy Short-stay outlier policy No broad rural adjusters 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 Discussion Setting-specific adjusters would reinforce adverse incentives under existing separate payment systems. A higher-cost outlier policy helps ensure access to care for high-cost patients while protecting providers that treat them from large losses. A short-stay outlier policy protects the program form large overpayments and discourages premature discharges. Results do not support a broad rural or frontier adjustment. However, the Secretary should evaluate the need for an adjustment for lowvolume, isolated providers. COPYRIGHT 2016, AMRPA, WASHINGTON, DC 66

Design features No IRF teaching adjustment More data regarding an adjustment for providers treating high shares of low-income patients MedPAC: Summary of Findings for a PAC PPS Discussion Results do not support an IRF adjustment. Combined with an outlier policy, risk adjustment could establish accurate payments. 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. Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC COPYRIGHT 2016, AMRPA, WASHINGTON, DC 67

MedPAC: Summary of Findings for a PAC PPS Impact of changes Payment shifts among types and stays Payment shifts among providers and settings More information profitability across types of 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. Changes in payments reflect a provider s mix of the types of stays it treats, its therapy practices, and its existing cost structures. Change dampen incentive to selectively admit certain type of patients. Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC COPYRIGHT 2016, AMRPA, WASHINGTON, DC 68

Conforming regulatory requirements Near term: Waiving of select regulatory requirements Longer term: Core set of requirements for all PAC providers and specific requirements to treat patients with specialized care needs Standardized beneficiary cost sharing for PAC MedPAC: Summary of Findings for a PAC PPS The Secretary should evaluate which settingspecific 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. Core and specific requirements move toward uniform requirements across settings and provide flexibility to treat specialized patient care needs. 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) Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC COPYRIGHT 2016, AMRPA, WASHINGTON, DC 69

Implementation issues Level of payments Transition period Authority for Secretary to periodically revise and rebase payments MedPAC: Summary of Findings for a PAC PPS Some amount of rebasing is necessary to align payments and costs. 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. Refinements will maintain alignment of payments to costs. Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC COPYRIGHT 2016, AMRPA, WASHINGTON, DC 70

Comparison policies Readmission policy Value based purchasing that includes a resource a resource use measure MedPAC: Summary of Findings for a PAC PPS Readmissions policy counters the incentive to furnish poor-quality care that might result in hospital readmissions. Value-based purchasing ties payments to outcomes and helps prevent unnecessary service provision, including serial PAC stays. Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC COPYRIGHT 2016, AMRPA, WASHINGTON, DC 71

Monitoring Monitoring of quality, volume of PAC stays, and selective admissions Evaluate of the adequacy of Medicare payments MedPAC: Summary of Findings for a PAC PPS Note: PAC (Post-Acute Care), PPS (Prospective Payment System), IRF (Inpatient Rehabilitation Facility) 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). Evaluation signals whether payments are adequate to cover the costs of efficient providers in treating beneficiaries, thereby helping to ensure appropriate access to care. Source: Table 3-1, Chapter 3, June 2016 Report to the Congress, Medicare and the Health Care Delivery System, MedPAC, Washington, DC COPYRIGHT 2016, AMRPA, WASHINGTON, DC 72

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 COPYRIGHT 2016, AMRPA, WASHINGTON, DC 73