IRF PPS FY 2018 PROPOSED RULE: A DISCUSSION

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1 IRF PPS FY 2018 PROPOSED RULE: A DISCUSSION AMRPA WEBINAR JULY 19, 2017 Carolyn C. Zollar, M.A. J.D. Executive Vice President for Government Relations and Policy Development Mimi Zhang Policy and Research Associate AMRPA COPYRIGHT 2017, AMRPA, WASHINGTON, DC 1

4 Annual Rule Only Discussion However Remember Our World Is Moving to Alternative Payment Models (APM)Yet All Are So Far Based Off FFS ACO SHFFT CJR BPCI EPM: Cardiac Fee For Service PPSs COPYRIGHT 2017, AMRPA, WASHINGTON, DC 4

5 Spring Rules Season: Fee for Service Annual Events Each PPS Has Annual Proposed Rules or Notices IPPS/ LTCH SNF PPS IRF PPS MACRA HH PPS MPFS OPPS/ ASC Who is Missing? COPYRIGHT 2017, AMRPA, WASHINGTON, DC 5

6 Medicare FFS Annual Rules No Longer Simple Payment Rules Give CMS View on Multiple Issues Affecting Each PAC Space This Years IRF PPS Rule Covers: 1. IRF PPS Changes 2. ICD-10-CM Changes 3. Request for Comment on 60 Percent Rule: Open Season 4. Broad Request for Information (RFI) 5. Expansion of Quality Reporting Program (IRF QRP) 6. First Public Discussion and Proposals on Standard Patient Assessment Data (SPAD) under the IMPACT Act COPYRIGHT 2017, AMRPA, WASHINGTON, DC 6

Payment to IRFs: Review Routine Cost Limits 1972 1982 TEFRA IMPACT ACT TEFRA 1982 2002 IRF PPS January 1, 2002 Present What s

7 Payment to IRFs: Review Routine Cost Limits TEFRA IMPACT ACT TEFRA IRF PPS January 1, 2002 Present What s Next? Balanced Budget Act of 1997 Authorized It Refined FY 2006 PAC PPS? IMPACT Act etc. COPYRIGHT 2017, AMRPA, WASHINGTON, DC 7

8 IRF-PPS Inclusions And Exclusions Includes: Excludes: PPS Excluded Rehab Hospitals and Units in US & Territories Capital and Inpatient Operating Costs Hospitals and Units in Demo Programs (MD) Costs of Bad Debt, Educational Programs, Blood Clotting Factor Units Physician, PA, NP, Midwife, Qualified Psychologist & Anesthetists Services. COPYRIGHT 2017, AMRPA, WASHINGTON, DC 8

IRF-PPS Applies to Traditional FFS Medicare

Equated to Length of Stay Management Bad, Bad,

9 IRF-PPS Applies to Traditional FFS Medicare Cases Only Physician Billing is Separate - Part B Incentive is to Have the Patients Costs Remain Under Payment Received Most Often Equated to Length of Stay Management Bad, Bad, Bad Idea and CMS Agrees COPYRIGHT 2017, AMRPA, WASHINGTON, DC 9

10 IRF-PPS Basics Data Collection (IRF-PAI) Patient Classification System- Case Mix Groups (CMGs) Tiers 4 Per Discharge Payment Unit Adjusted For Facility Characteristics Facility Adjusters Rural, LIP, Medical Outlier Policy Special Payment Polices, Transfer, Interrupted Stay, Short Stay, Etc. COPYRIGHT 2017, AMRPA, WASHINGTON, DC 8

Medical Outlier Policy Special Payment Polices Transfer

12 IRF-PPS Basics Per Discharge Payment Unit Adjusted For Facility Characteristics Facility Adjusters Rural, LIP, Medical Outlier Policy Special Payment Polices Transfer Interrupted Stay Short Stay, Etc. COPYRIGHT 2017, AMRPA, WASHINGTON, DC 8

13 FY 2018 IRF PPS Proposed Rule Proposals FY 2018 IRF PPS Proposed Rule Federal Register / Vol. 82, No. 84 / Wednesday, May 3, 2017 MACRA Update 1% Only Budget Neutrality Facility Adjusters CMGs Updates COPYRIGHT 2017, AMRPA, WASHINGTON, DC 13

14 FY 2018 Proposed Rule Snapshot FY 2014 Final FY 2015 Final FY 2016 Final FY 2017 Final FY 2018 Proposed Rule Standard Payment Rate $14,846 $15,198 $15,478 $15,708 $15,835 Outlier Threshold $9,272 $8,848 $8,658 $7,954 $8,656 Labor Share Facility Adjusters: No Change LIP Factor: Rural Adjustment: 14.9% Teaching Adjustment: Case Mix Groups Recalibrated, Table 2 COPYRIGHT 2017, AMRPA, WASHINGTON, DC 14

15 FY 2018 IRF PPS Proposed Rule: Facility Adjusters - Yet Again No Changes To Recognize Provider Costs Not Included In CMG Weights LIP Factor Frozen Rural Percentage 14.9 % Teaching Factor Frozen at FY 2014 Levels When Will It Reexamine Them? No Hints COPYRIGHT 2017, AMRPA, WASHINGTON, DC 15

16 Difference Between Medicare Payment and Provider Cost for FY 2018 Based on FY 2018 IRF PPS Proposed Rule (includes outlier payments) WA ME OR ID MT WY ND SD MN WI MI NY VT NH MA CT RI CA NV UT CO NE KS IA MO IL IN OH KY WV PA MD VA NJ DE AK HI AZ NM TX OK AR LA MS TN AL GA NC SC FL Getting Greener Each Year! Payment is lower than cost Payment is higher than cost Changes from 2017 to 2018 MI, NC, SD, WY DE Source: CMS FY 2018 IRF PPS Proposed Rule Rate Setting File AMRPA, Washington, DC, 2017 COPYRIGHT 2017, AMRPA, WASHINGTON, DC 16

17 IRF PPS Payment Formula P = 1. (Standard Federal Payment Amount) x (CMG Weight 1 ) x 2. Labor Share = 3. Labor Portion of Federal Payment x 4. (Wage Index) = Wage Adjusted Amount 5. Non Labor Amount Wage Adjusted Federal Payment x 6. Rural Adjustment x LIP Adjustment = Wage, Rural, LIP Adjusted/FPP 1. Calculated from age, motor and cognitive function and comorbidities 2. Non labor amount = Unadjusted Federal Prospective Payment Labor COPYRIGHT 2017, AMRPA, WASHINGTON, DC 9

18 P = 6. Wage and Rural Adjusted Payment Only + 7. Teaching Status Adjustment x = 8. Teaching Status Adjustment Amount 3 = 9. Teaching Status Adjustment + Wage, Rural, LIP Adjusted Rate = Total Payment 10. Outlier (0.80 x (Cost Outlier Threshold + CMG Payment) 3. Can be + or - IRF PPS Payment Formula Taken from Table 6, Examples of Computing the IRF FY 2018 Federal Prospective Payment, FY 2018 IRF PPS Proposed Rule pg COPYRIGHT 2017, AMRPA, WASHINGTON, DC 10

19 Table 6 Example of Computing the FY 2018 IRF Prospective Payment Steps Rural facility A (Spencer Co., IN) 1. Unadjusted Payment $33, $33, Labor Share Labor Portion of Payment = $23, = $23, CBSA-Based Wage Index (shown in the Addendum, Tables A and B) Wage-Adjusted Amount = $19, = $20, Non-Labor Amount + $9, $9, Wage-Adjusted Payment = $29, = $30, Rural Adjustment Wage- and Rural-Adjusted Payment = $33, = $30, LIP Adjustment Wage-, Rural- and LIP-Adjusted Payment = $33, = $32, Wage- and Rural-Adjusted Payment $33, $30, Teaching Status Adjustment Teaching Status Adjustment Amount = $0.00 = $2, Wage-, Rural-, and LIP-Adjusted Payment + $33, $32, Total Adjusted Payment = $33, = $34, FY 2018 IRF PPS Proposed Rule pg COPYRIGHT 2017, AMRPA, WASHINGTON, DC 19

20 FY 2018 Proposed Rule Addresses TBI Code, Hip Fractures and Major Multiple Trauma Issues Changes TBI-IGCs 2.21 TBI-IGCs 2.22 Hip Fracture Unilateral Bilateral 8.11 COPYRIGHT 2017, AMRPA, WASHINGTON, DC 20

21 FY 2018 Proposed Rule Proposes to Remove: 15 Rheumatoid Polyneuropathy and Arthritis Codes Certain Arthritis Codes and Unspecified Codes Other Specified Myopathies COPYRIGHT 2017, AMRPA, WASHINGTON, DC 21

22 Impact of ICD-10 Changes Per erehabdata Increase in Presumptive Compliance of 1.63% on Average to 65.19% w/cc Select IGCs: TBI 02.22: % Neurological 03.8: % Osteoarthritis 06.2: -25% Neuro is Primarily ICD-10 G72.89 and IGC 03.8 RIC 08 Hip Fracture: % Other Losses Due to Removal of Unspecified Codes COPYRIGHT 2017, AMRPA, WASHINGTON, DC 22

23 FY 2018 Proposed Rule Requests for Information (RFI) 1. On 60% Rule 2. Anything You Want To Say Regarding All Rules, Policies, Manuals, Procedures, Etc.! What a Field Day! COPYRIGHT 2017, AMRPA, WASHINGTON, DC 23

24 AMRPA s Comments: FY 2018 Proposed Rule Request for Information (RFI) Eliminate 60% Rule Revise 3 Hour Rule Implement Continuing Care Hospital (CCH) Change Appeals/Denials Process Example: Eliminate Technical Denials See AMRPA FY 2018 NPRM Comment Letter on AMRPA website. COPYRIGHT 2017, AMRPA, WASHINGTON, DC 24

25 IMPACT Act: Second Leg Standard Payment Assessment Data Roll Out of First Set of Items Two More Steps To Come Why So Important: Bricks for Future Payment System and Quality Measures COPYRIGHT 2017, AMRPA, WASHINGTON, DC 25

27 Three Reporting Sites/Methods for 17 Measures 10/1/16; Many Respond to IMPACT Act Via IRF PAI v.1.4 (Move to CY Basis) Via NHSN (CY Basis) Via Claims Data Pressure Ulcers Patient Influenza Vaccination 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) CAUTI MRSA C. Diff Healthcare Personnel Influenza Vaccination All-Cause Readmissions 30- Days Post Discharge (Proposed for Removal) Potentially Preventable Readmissions Post Discharge Potentially Preventable Readmissions Within-Stay Discharge to Community MSPB COPYRIGHT 2017, AMRPA, WASHINGTON, DC 27

FY 2018 Proposed Rule IRF QRP Modifies Pressure Ulcer Measure Beginning

Unplanned Readmission Measure Beginning FY 2019 IRF QRP Performance Year

Experience of Care Survey Modify Discharge to Community by Excluding

28 FY 2018 Proposed Rule IRF QRP Modifies Pressure Ulcer Measure Beginning October 1, 2018 (FY 2020 IRF QRP Performance Year) Remove All-Cause Unplanned Readmission Measure Beginning FY 2019 IRF QRP Performance Year Transfer of Information at Admission and Discharge (Required by IMPACT Act) Experience of Care Survey Modify Discharge to Community by Excluding Baseline SNF Residents CMS Is Considering a Pain Measure COPYRIGHT 2017, AMRPA, WASHINGTON, DC 28

Public Reporting: IRF Compare https://www.medicare.

30 IRF QRP Public Reporting: Previously Finalized Measures 1. Pressure Ulcers* (Will Be Replaced with Modified Pressure Ulcer Measure) 2. CAUTI* 3. All-Cause Readmissions* 4. MRSA 5. Healthcare Personnel Influenza Vaccination 6. Patient Influenza Vaccination *Currently Displayed on IRF Compare COPYRIGHT 2017, AMRPA, WASHINGTON, DC 30

31 FY 2018 Proposed Rule IRF QRP Public Reporting Proposes 6 Additional Measures for Public Reporting for CY 2018: 1. Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631) (assessment-based) 2. Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674) (assessment-based) 3. Medicare Spending Per Beneficiary-PAC IRF QRP (claims-based) 4. Discharge to Community-PAC IRF QRP (claims-based) 5. Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP (claims-based) 6. Potentially Preventable Within Stay Readmission Measure for IRFs (claims-based) COPYRIGHT 2017, AMRPA, WASHINGTON, DC 31

32 FY 2018 Proposed Rule IRF QRP Standard Patient Assessment Data (SPAD) Domain: Functional Status Data Percent of Patients with Admission and Discharge Functional Assessment and Care Plan That Addresses Function (NQF #2631) COPYRIGHT 2017, AMRPA, WASHINGTON, DC 32

would need to be reported for patient admission and discharge, the BIMS would only be

33 FY 2018 Proposed Rule IRF QRP-SPAD Domain: Cognitive Function and Mental Status Data Brief Interview for Mental Status (BIMS): Unlike most of the other data elements which would need to be reported for patient admission and discharge, the BIMS would only be required at admission. Confusion Assessment Method (CAM) COPYRIGHT 2017, AMRPA, WASHINGTON, DC 33

FY 2018 Proposed Rule IRF QRP-SPAD Domain: Cognitive Function and Mental Status Data Behavioral Signs and Symptoms CMS proposes to add data elements Behavioral Signs and Symptoms to the IRF

34 FY 2018 Proposed Rule IRF QRP-SPAD Domain: Cognitive Function and Mental Status Data Behavioral Signs and Symptoms CMS proposes to add data elements Behavioral Signs and Symptoms to the IRF PAI. Patient Health Questionnaire (PHQ-2) CMS proposes to add the two-item PHQ-2 to the IRF PAI to assess patients for depressed mood and anhedonia. COPYRIGHT 2017, AMRPA, WASHINGTON, DC 34

35 FY 2018 Proposed Rule IRF QRP - SPAD Special Services, Treatments, and Impairments CMS proposes to add data elements for 17 special services, treatments, and interventions that it has identified for cross-setting reporting from PAC providers. Many are already on MDS, OASIS, LTCH Assessments 1. Cancer Treatment: Chemotherapy (IV, Oral, Other) 2. Cancer Treatment: Radiation 3. Respiratory Treatment: Oxygen Therapy (Continuous, Intermittent) 4. Respiratory Treatment: Suctioning (Scheduled, As needed) 5. Respiratory Treatment: Tracheostomy Care COPYRIGHT 2017, AMRPA, WASHINGTON, DC 35

36 FY 2018 Proposed Rule IRF QRP - SPAD Special Services, Treatments, and Impairments 6. Respiratory Treatment: Non-invasive mechanical ventilation (BiPAP, CPAP) 7. Respiratory Treatment: Invasive mechanical ventilator 8. Other Treatment: Intravenous (IV) Medications 9. Other Treatment: Transfusions 10. Other Treatment: Dialysis (Hemodialysis, Peritoneal dialysis) 11. Other Treatment: IV Access (Peripheral IV, Midline, Central line, Other) COPYRIGHT 2017, AMRPA, WASHINGTON, DC 36

37 FY 2018 Proposed Rule IRF QRP - SPAD Special Services, Treatments, and Impairments 12. Nutritional Approach: Parenteral/IV Feeding 13. Nutritional Approach: Feeding Tube 14. Nutritional Approach: Mechanically Altered Diet 15. Nutritional Approach: Therapeutic Diet 16. Impairments: Hearing 17. Impairments: Vision COPYRIGHT 2017, AMRPA, WASHINGTON, DC 37

0 Will Expand IRF PAI to 24 Pages from v 1.

39 FY 2018 Proposed Rule IRF PAI Changes Remove the 25% Payment Penalty for Late IRF PAI Submissions Remove Voluntary Item 27 Swallowing Status Use IRF PAI Information to Calculate BMI>50 for Lower Extremity Single Joint Replacements to Count Qualifying Patients in 60% Rule (Presumptive Compliance) COPYRIGHT 2017, AMRPA, WASHINGTON, DC 39

42 IMPACT Act of 2014: Timeline for IRH/Us and HHS PROVIDERS HHS, MEDPAC Oct 1, 2016 IRH/Us Start Reporting: 3 of 5 Quality Measures (Functional Status, Skin Integrity, Falls) All Resource Use Measures Jan 2016 CMS Promulgates Regulations to Modify COP (once every 5 years) Oct 1, 2017 CMS Issues Providers Performance Reports 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, 2018 IRH/Us Start Reporting: Standardized Patient Assessment Data (SPAD) Remaining 2 Quality Measures (Medication Reconciliation, Patient Care Preferences) Oct 1, 2018 Provider Performance Reports Made Public CMS Matches Claims to Patient Assessment Data Oct 2019 ASPE Report on Impact of Risk Factors on Quality and Resource Measures Jan 1, 2021 CMS Report Recommending PAC PPS Technical Prototype June 30, 2021 MedPAC Report Recommending PAC PPS Technical Prototype COPYRIGHT 2017, AMRPA, WASHINGTON, DC 42

43 IRF Resources for Public Reporting Assessment Submission: User Guides & Training page on the QIES Technical Support Office (QTSO) Web site: CASPER Reports: IRF User Guides & Training page on the QIES Technical Support Office (QTSO) Web site: IRF Public Reporting Help Desk CMS August 23 Webinar: Quality Reporting Program Provider Training Instruments/IRF-Quality-Reporting/Downloads/IRF-LTCH-Public-Reporting- Webinar PDF Copyright 2017, AMRPA, Washington, DC 43

44 CMS CONTACT INFORMATION 1. CMS Help Desk For all questions related to recording data on the IRF patient assessment instrument (IRF-PAI) or using the Inpatient Rehabilitation Validation Entry (IRVEN) Software: Phone: Fax: Coverage Hours: 8:00am (ET) to 8:00pm (ET) Monday through Friday Please note: The CMS Help Desk experiences a high volume of calls. To receive priority, please send an inquiry and include 'IRF Clinical' in the subject line. 2. Helpdesk Resources for IRF Providers a) If you have questions about Quality Reporting Program & Quality Reporting Items such as: IRF QRP requirements IRF QRP data submission timelines Pressure ulcer coding Pressure ulcer staging Wounds Patient influenza vaccine coding 30-day post discharge all-cause unplanned readmission measure IRF QRP and Quality Indicator provider training materials General quality reporting questions Contact IRF.Questions@cms.hhs.gov COPYRIGHT 2017, AMRPA, WASHINGTON, DC 44

45 Helpdesk Resources for IRF Providers c cont d CMS CONTACT INFORMATION b) If you have questions about IRF-PAI data completion, submission, or validation such as: Accessing QIES (username and password) Completing the clinical items on the IRF-PAI (for nonquality related sections) Data/record submissions Submission/validation reports CASPER reports jirven Contact Help@qtso.com or call c) If you have questions about the IRF Coverage Requirements or Medicare payment policies such as: IRF Medicare Reimbursement Claims/Coding Eligibility, coverage, documentation and therapy time requirements IRF-PAI late transmission payment penalty waiver requests and questions IRF-PAI requirements (for non-quality sections) 25% Waiver Requests Contact IRFCoverage@cms.hhs.gov COPYRIGHT 2017, AMRPA, WASHINGTON, DC 45

46 CMS CONTACT INFORMATION d) If you have questions about the CDC or NHSN, such as: Centers for Disease Control (CDC) quality measures, such as Catheter Associated Urinary Tract Infections (CAUTI) National Healthcare Safety Network (NHSN) enrollment and reporting Contact e) If you have questions about the IRF Quality Reporting Program Reconsideration Process, such as: How to file a Request for Reconsideration if you receive a letter of non-compliance from CMS for the IRF Quality Reporting Program? What is the deadline for filing a Request for Reconsideration? How to dispute a finding of non-compliance with the ACA 3004 IRF QRP reporting requirements that can lead to about a 2% payment reduction? Requesting information about the ACA 3004 IRF Quality Reporting Program payment reduction for failure to report required quality data Contact IRFQRPReconsiderations@cms.hhs.gov COPYRIGHT 2017, AMRPA, WASHINGTON, DC 46

47 CMS CONTACT INFORMATION 3. Helpdesk Resources for IRF Vendors If you have questions about Vendor Issues, such as: IRF-PAI data specifications VUT (vendor tool to ensure software meets CMS requirements and will pass ASAP edits) Technical questions related to IRF-PAI data specifications 4. Toll-Free Customer Service for IRF billing/payment questions See the Medicare Learning Network webpage Learning-Network- MLN/MLNGenInfo/index.html?redirect=/mlngeninfo A document on this page provides toll-free customer service numbers for the fiscal intermediaries and Medicare Administrative Contractors (MACs). Contact IRFTechIssues@cms.hhs.gov COPYRIGHT 2017, AMRPA, WASHINGTON, DC 47

48 CMS CONTACT INFORMATION 5. Data Submission VPN Secure Connection (CMSNet( CMSNet) Phone: Example of issues this resource can help you with: Accessing CMSNet Juniper client (username and password) 6. Additional IRF Information CMS publications related to the IRF PPS website: Payment/InpatientRehabFacPPS/index.html Clarifications for IRF Coverage Requirements Website: Payment/InpatientRehabFacPPS/Coverage.html Information for IRF PPS claims and the matching process with the IRF-PAI Website: and-education/medicare-learning-network- MLN/MLNMattersArticles/Downloads/SE1342.pdf COPYRIGHT 2017, AMRPA, WASHINGTON, DC 48

BY-STATE MENTAL HEALTH SERVICES AND EXPENDITURES IN MEDICAID, 1999

STATE-BY BY-STATE MENTAL HEALTH SERVICES AND EXPENDITURES IN MEDICAID, 1999 James Verdier,, Ann Cherlow,, and Allison Barrett Mathematica Policy Research, Inc. Jeffrey Buck and Judith Teich Substance Abuse