IRF PPS FY 2020 Proposed Rule Conference Call: May 22, 2019 IRF - PowerPoint PPT Presentation

IRF PPS FY 2020 Proposed Rule Conference Call: May 22, 2019

IRF PPS Proposed Payment Update

FY 2019 Final Rule – IRF PPS Reforms Effective October 1, 2019 – Recalibrate the CMGs – Use most recent two years of data to recalibrate the case mix groups (CMG), relative weights and average length of stay values for FY 2020. o FYs 2017 and 2018. – Use Section GG data to assign payments (instead of FIM data) o Cease use of FIM – Budget neutral; no behavioral adjustment. – CMS’s stated objectives for these changes: o Standardized data collection across the PAC settings; o Update the CMGs after 15+ years in use; and o Reduced administrative burden. (Cost savings: $9,100 per IRF)

FY 2020 Proposed Rule – PAYMENT Proposed Payment Update for FY 2020 • 2.3% payment increase ─ $195 million increase over FY 2019 payments ─ Standard Payment: ─ FY 2019: 16,021 ─ FY 2020: $16,573 ─ Rebase and revise the IRF market basket (2016 data instead of 2012) ─ Table 8 in proposed rule: Compares new and proposed cost categories and weights ─ The facility adjustments (LIP, Rural, Teaching) would remain unchanged. – CMS Impact Estimate: Overall changes favor units, certain rural, non- profits, & govt-owned IRFs.

FY 2020 Proposed Rule: CMG Refinements • 97 CMGs instead of 92 • Fewer CMGs in RICs 1, 2, 5, and 8 • More CMGs in RICs 3, 4, 10, 11, 12, 13, 16, 18, 19 and 21 • Age would affect CMG assignment for RICs 1, 3, 4, 12, 13, 16 and 20. – Today, age affects RICs, 1, 4 and 8. • Intended to be a budget-neutral change, buy payments would be redistributed across the CMGs. – CMS Impact Estimate for Case Re-distribution of Payments: o Urban unit: +2.5% o Rural unit: +2.9% Urban hospital: -2.2% o Rural hospital: -3.6% o

FY 2020 Proposed Rule – New Motor Score Weighting Methodology − FY 2019 Final Rule : − Use an unweighted additive motor score to assign patients to a CMG. − Use 19 quality indicators: Eating, oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear, bladder continence, bowel continence, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10 feet, walk 50 feet with two turns, walk 150 feet, and 1 step (curb.) − Rationale: Unweighted score is less complex and easier to understand. − FY 2020 Proposed Rule : − Use a weighted motor score. − Use 18 quality indicators (Omit “roll left to right” since unstable in various regression models.) − Rationale: RTI found that the weighted motor score “slightly improves” the accuracy of cost predictions. − Concern: Proposed weight values significantly changed from FY 2019. ─ Today: Most weight value assigned to mobility items ─ Proposed: Most weight value assigned to self-care items ─ What is CMS’s rationale for this shift? ─ Impact on patient access and payment accuracy?

FY 2020 Proposed Rule – Definition of Rehabilitation Physician • Existing definition: “A licensed physician with specialized training and experience in inpatient rehabilitation.” • Proposed addition: Allow each IRF to determine for its own facility/ies, which physicians qualify as a rehabilitation physician under the existing definition. • CMS: “…we believe that the IRFs are in the best position to make this determination.” • Pro-provider position. 7

IRF PPS Proposed Quality Reporting Update

New Quality Measures for FY 2022  Transfer of Health Information to the Provider  Transfer of Health Information to the Patient  Reviewed by NQF MAP, but not (yet?) endorsed  Asks whether facility provided reconciled medication list to subsequent provider (if discharged/transferred to another facility) or patient/family/caregiver (if discharged to home)  Also asks for route of transmission (e.g. EHR, verbal, paper, HIE)  Not risk-adjusted or stratified  If finalized, data submission required starting with Oct. 1, 2020 discharges

Other QRP Updates  Update to Discharge to Community measure  Exclude baseline nursing facility patients  Publicly report Drug Regiment Review Conducted with Follow-Up for Identified Issues beginning CY 2020  Expand reporting of assessment data for QRP to all patients, regardless of payer  No longer publish list of compliant providers beginning FY 2020

Standardized Patient Assessment Data Elements  IMPACT Act requires “standardized and interoperable quality measures and patient assessment data” in five domains  Functional Status  Cognitive Function  Special Services, Treatments, and Interventions  Medical Conditions and Comorbidities  Impairments  FY18 Proposed Rules: CMS proposes to adopt dozens of data elements all at once. Faces severe backlash, led by AHA  In response, does not finalize proposals; establishes elements already reported on Functional Status and Medical Conditions (Pressure Ulcer) to meet IMPACT Act requirements  2017-2019: Contracts with RAND and Abt Associations to conduct National Beta Test on candidate SPADEs

FY20 Proposed Rule: SPADEs 2.0  Proposed 22 SPADE items, mostly from MDS and OASIS (very few in IRF-PAI and LCDS)  Associated with potentially more than 60 additional data elements to complete for IRFs and LTCHs  Several elements associated with 0-3% of patient assessments in National Beta Test  Also proposes new domain: Social Determinants of Health  7 elements: Race, Ethnicity, Preferred Language, Interpreter Services, Health Literacy, Transportation, Social Isolation  Providers would be required to collect and report with respect to admission and discharge for patients discharged between Oct. 1, 2020 and Dec. 31, 2020 (and then for each subsequent calendar year)

RFI on Future Measure & SPADE Topics  Opioid use and frequency  Exchange of electronic health information and interoperability  More SPADEs:  Cognitive complexity; dementia  Bladder and bowel continence  Care preferences, advance care directives, goals of care  Caregiver status  Veteran status  Health disparities and risk factors (education, sex and gender identity, sexual orientation)

IRF PPS FY 2020 Comment Letter

Comment Letter Deadline: June 17 Sample of Top Issues • Industry estimates: Payments drop 3-5% based on “most usual performance” (instead of lowest function) during initial 36 hours. • New rating scale for Section GG are different and more restrictive; less sensitive for lower-functioning patients. o Providers still struggling with coding instructions; inconsistent reporting leads to possible data inaccuracies. • Unable to model the impact of the new weighting methodology with limited data provided by CMS. • Lack of data prevents determination of patient groupings into particular CMGs, as well as associated payment weights and LOS values for each CMG. In other words, can’t replicate payments. • Concerns re rationale, methodology and impact of proposed weighted motor score. • Encouraging CMS to wait until the two new measures proposed for adoption receive NQF endorsement before implementation into the quality reporting programs. • Implement new standardized patient assessment data elements more gradually, and reconsider addition elements that are not relevant for IRF and LTCH populations. • Support the removal of baseline nursing facility residents from the Discharge to Community measure calculation. 15

DISCUSSION

CONTACT: Rochelle Archuleta & Caitlin Gillooley AHA Policy 202-638-1100 rarchuleta@aha.org cgillooley@aha.org MATERIALS: www.aha.org/postacute