[Federal Register Volume 83, Number 151 (Monday, August 6, 2018)]
[Rules and Regulations]
[Pages 38514-38573]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-16517]
[[Page 38513]]
Vol. 83
Monday,
No. 151
August 6, 2018
Part III
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Part 412
Medicare Program; Inpatient Rehabilitation Facility Prospective Payment
System for Federal Fiscal Year 2019; Rules
Federal Register / Vol. 83, No. 151 / Monday, August 6, 2018 / Rules
and Regulations
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 412
[CMS-1688-F]
RIN 0938-AT25
Medicare Program; Inpatient Rehabilitation Facility Prospective
Payment System for Federal Fiscal Year 2019
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule updates the prospective payment rates for
inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY)
2019. As required by the Social Security Act (the Act), this final rule
includes the classification and weighting factors for the IRF
prospective payment system's (PPS) case-mix groups and a description of
the methodologies and data used in computing the prospective payment
rates for FY 2019. This final rule also alleviates administrative
burden for IRFs by removing the Functional Independence Measure
(FIM\TM\) instrument and associated Function Modifiers from the IRF
Patient Assessment Instrument (IRF-PAI) beginning in FY 2020 and
revises certain IRF coverage requirements to reduce the amount of
required paperwork in the IRF setting beginning in FY 2019.
Additionally, this final rule incorporates certain data items located
in the Quality Indicators section of the IRF-PAI into the IRF case-mix
classification system using analysis of 2 years of data beginning in FY
2020. For the IRF Quality Reporting Program (QRP), this final rule
adopts a new measure removal factor, removes two measures from the IRF
QRP measure set, and codifies a number of program requirements in our
regulations.
DATES:
Effective Dates: These regulations are effective on October 1,
2018.
Applicability Dates: The updated IRF prospective payment rates are
applicable for IRF discharges occurring on or after October 1, 2018,
and on or before September 30, 2019 (FY 2019). In addition, the
revisions to certain IRF coverage requirements to reduce the amount of
required paperwork in the IRF setting and the updated measures and
reporting requirements under the IRF QRP are applicable for IRF
discharges occurring on or after October 1, 2018. The removal of the
FIM\TM\ instrument and associated Function Modifiers from the IRF-PAI
and refinements to the case-mix classification system are applicable
for IRF discharges occurring on or after October 1, 2019.
FOR FURTHER INFORMATION CONTACT:
Gwendolyn Johnson, (410) 786-6954, for general information.
Catie Kraemer, (410) 786-0179, for information about the IRF
payment policies and payment rates.
Kadie Derby, (410) 786-0468, for information about the IRF coverage
policies.
Christine Grose, (410) 786-1362, for information about the IRF
quality reporting program.
SUPPLEMENTARY INFORMATION: The IRF PPS Addenda along with other
supporting documents and tables referenced in this final rule are
available through the internet on the CMS website at http://www.cms.hhs.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/.
To assist readers in referencing sections contained in this
document, we are providing the following Table of Contents.
Table of Contents
Executive Summary
A. Purpose
B. Summary of Major Provisions
C. Summary of Impacts
D. Improving Patient Outcomes and Reducing Burden Through
Meaningful Measures
I. Background
A. Historical Overview of the IRF PPS
B. Provisions of the PPACA Affecting the IRF PPS in FY 2012 and
Beyond
C. Operational Overview of the Current IRF PPS
D. Advancing Health Information Exchange
II. Summary of Provisions of the Proposed Rule
III. Analysis and Responses to Public Comments
IV. Update to the Case-Mix Group (CMG) Relative Weights and Average
Length of Stay Values for FY 2019
V. Facility-Level Adjustment Factors
VI. FY 2019 IRF PPS Payment Update
A. Background
B. FY 2019 Market Basket Update and Productivity Adjustment
C. Labor-Related Share for FY 2019
D. Wage Adjustment for FY 2019
E. Description of the IRF Standard Payment Conversion Factor and
Payment Rates for FY 2019
F. Example of the Methodology for Adjusting the Prospective
Payment Rates
VII. Update to Payments for High-Cost Outliers Under the IRF PPS for
FY 2019
A. Update to the Outlier Threshold Amount for FY 2019
B. Update to the IRF Cost-to-Charge Ratio Ceiling and Urban/
Rural Averages for FY 2019
VIII. Removal of the FIMTM Instrument and Associated
Function Modifiers From the IRF-PAI Beginning With FY 2020 and
Refinements to the Case-Mix Classification System Beginning With FY
2020
A. Removal of the FIMTM Instrument and Associated
Function Modifiers From the IRF-PAI Beginning With FY 2020
B. Refinements to the Case-Mix Classification System Beginning
With FY 2020
IX. Revisions to Certain IRF Coverage Requirements Beginning With FY
2019
A. Changes to the Physician Supervision Requirement Beginning
With FY 2019
B. Changes to the Interdisciplinary Team Meeting Requirement
Beginning With FY 2019
C. Changes to the Admission Order Documentation Requirement
Beginning With FY 2019
D. Summary of Comments Regarding Additional Changes to the
Physician Supervision Requirement
E. Summary of Comments Regarding Changes to the Use of Non-
Physician Practitioners in Meeting the Requirements Under Sec.
412.622(a)(3), (4), and (5)
X. Updates to the IRF Quality Reporting Program (QRP)
A. Background
B. General Considerations Used for Selection of Measures for the
IRF QRP
C. New Removal Factor for Previously Adopted IRF QRP Measures
D. Quality Measures Currently Adopted for the FY 2020 IRF QRP
E. Removal of Two IRF QRP Measures
F. IMPACT Act Implementation Update
G. Form, Manner, and Timing of Data Submission Under the IRF QRP
H. Changes to the Reconsideration Requirements Under the IRF QRP
I. Policies Regarding Public Display of Measure Data for the IRF
QRP
J. Method for Applying the Reduction to the FY 2019 IRF Increase
Factor for IRFs That Fail To Meet the Quality Reporting Requirements
XI. Miscellaneous Comments
XII. Provisions of the Final Regulations
XIII. Request for Information on Promoting Interoperability and
Electronic Healthcare Information Exchange Through Possible
Revisions to the CMS Patient Health and Safety Requirements for
Hospitals and Other Medicare- and Medicaid-Participating Providers
and Suppliers
XIV. Collection of Information Requirements
A. Statutory Requirement for Solicitation of Comments
B. Collection of Information Requirements for Updates Related to
the IRF PPS
C. Collection of Information Requirements for Updates Related to
the IRF QRP
XV. Regulatory Impact Analysis
A. Statement of Need
B. Overall Impacts
C. Anticipated Effects
D. Alternatives Considered
E. Regulatory Review Costs
F. Accounting Statement and Table
G. Conclusion
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Regulatory Text
Executive Summary
A. Purpose
This final rule updates the prospective payment rates for IRFs for
FY 2019 (that is, for discharges occurring on or after October 1, 2018,
and on or before September 30, 2019) as required under section
1886(j)(3)(C) of the Act. As required by section 1886(j)(5) of the Act,
this rule includes the classification and weighting factors for the IRF
PPS's case-mix groups and a description of the methodologies and data
used in computing the prospective payment rates for FY 2019. In
addition, this final rule reduces the regulatory burden for IRFs by
removing data items from the IRF-PAI and revising certain IRF coverage
and paperwork requirements. The final rule also updates requirements
for the IRF QRP, including adding a new quality measure removal factor,
removing two measures from the measure set, and codifying a number of
program requirements in our regulations.
B. Summary of Major Provisions
In this final rule, we use the methods described in the FY 2018 IRF
PPS final rule (82 FR 36238) to update the prospective payment rates
for FY 2019 using updated FY 2017 IRF claims and the most recent
available IRF cost report data, which is FY 2016 IRF cost report data.
(Note: In the interest of brevity, the rates previously referred to as
the ``Federal prospective payment rates'' are now referred to as the
``prospective payment rates''. No change in meaning is intended.) We
are also finalizing our proposals to alleviate administrative burden
for IRFs by removing the FIMTM instrument and associated
Function Modifiers from the IRF-PAI and revising certain IRF coverage
requirements to reduce the amount of required paperwork in the IRF
setting. We are also finalizing updates to requirements for the IRF
QRP.
C. Summary of Impacts
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Provision description Transfers
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FY 2019 IRF PPS payment rate The overall economic impact of this final
update. rule is an estimated $105 million in
increased payments from the Federal
government to IRFs during FY 2019.
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Provision Description Costs
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Removal of FIM\TM\ Items from The total reduction in costs in FY 2020
IRF-PAI. for IRFs as a result of the removal of
the FIM\TM\ instrument and associated
Function Modifiers from the IRF[dash]PAI
is estimated to be $10.5 million.
Removal of certain IRF The total reduction in costs in FY 2019
coverage requirements. for IRFs as a result of the removal of
certain IRF coverage requirements is
estimated to be $20.5 million.
New IRF QRP requirements..... The total reduction in costs in FY 2019
for IRFs as a result of the new quality
reporting requirements is estimated to
be $2.5 million.
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D. Improving Patient Outcomes and Reducing Burden Through Meaningful
Measures
Regulatory reform and reducing regulatory burden are high
priorities for CMS. To reduce the regulatory burden on the healthcare
industry, lower health care costs, and enhance patient care, in October
2017, we launched the Meaningful Measures Initiative.\1\ This
initiative is one component of our agency-wide Patients Over Paperwork
Initiative,\2\ which is aimed at evaluating and streamlining
regulations with a goal to reduce unnecessary cost and burden, increase
efficiencies, and improve beneficiary experience. The Meaningful
Measures Initiative is aimed at identifying the highest priority areas
for quality measurement and quality improvement in order to assess the
core quality of care issues that are most vital to advancing our work
to improve patient outcomes. The Meaningful Measures Initiative
represents a new approach to quality measures that fosters operational
efficiencies, and will reduce costs, including collection and reporting
burden while producing quality measurement that is more focused on
meaningful outcomes.
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\1\ Meaningful Measures web page: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/MMF/General-info-Sub-Page.html.
\2\ See Remarks by Administrator Seema Verma at the Health Care
Payment Learning and Action Network (LAN) Fall Summit, as prepared
for delivery on October 30, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-10-30.html.
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The Meaningful Measures Framework has the following objectives:
Address high-impact measure areas that safeguard public
health;
Patient-centered and meaningful to patients;
Outcome-based where possible;
Fulfill each program's statutory requirements;
Minimize the level of burden for health care providers
(for example, through a preference for EHR-based measures where
possible, such as electronic clinical quality measures);
Significant opportunity for improvement;
Address measure needs for population based payment through
alternative payment models; and
Align across programs and/or with other payers.
In order to achieve these objectives, we have identified 19
Meaningful Measures areas and mapped them to six overarching quality
priorities as shown in the Table 1:
Table 1--Meaningful Measures Framework Domains and Measure Areas
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Quality priority Meaningful Measure area
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Making Care Safer by Healthcare-Associated Infections.
Reducing Harm Caused in the Preventable Healthcare Harm.
Delivery of Care.
Strengthen Person and Family Care is Personalized and Aligned with Patient's Goals.
Engagement as Partners in
Their Care.
End of Life Care according to Preferences.
Patient's Experience of Care.
Patient Reported Functional Outcomes.
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Promote Effective Medication Management.
Communication and Admissions and Readmissions to Hospitals.
Coordination of Care.
Transfer of Health Information and Interoperability.
Promote Effective Prevention Preventive Care.
and Treatment of Chronic Management of Chronic Conditions.
Disease.
Prevention, Treatment, and Management of Mental Health.
Prevention and Treatment of Opioid and Substance Use Disorders.
Risk Adjusted Mortality.
Work with Communities to Equity of Care.
Promote Best Practices of Community Engagement.
Healthy Living.
Make Care Affordable........ Appropriate Use of Healthcare.
Patient-focused Episode of Care.
Risk Adjusted Total Cost of Care.
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By including Meaningful Measures in our programs, we believe that
we can also address the following cross-cutting measure criteria:
Eliminating disparities;
Tracking measurable outcomes and impact;
Safeguarding public health;
Achieving cost savings;
Improving access for rural communities; and
Reducing burden.
We believe that the Meaningful Measures Initiative will improve
outcomes for patients, their families, and health care providers while
reducing burden and costs for clinicians and providers, as well as
promoting operational efficiencies.
Comment: We received numerous comments from stakeholders regarding
the Meaningful Measures Initiative and the impact of its implementation
in CMS' quality programs. Many of these comments pertained to specific
program proposals, and are discussed in the appropriate program-
specific sections of this final rule. However, commenters also provided
insights and recommendations for the ongoing development of the
Meaningful Measures Initiative generally, including: Ensuring
transparency in public reporting and the usability of publicly reported
data; evaluating the benefit of individual measures to patients via
their use in quality programs versus the burden to providers of
collecting and reporting that measure data; and identifying additional
opportunities for alignment across CMS quality programs.
Response: We will continue to work with stakeholders to refine and
further implement the Meaningful Measures Initiative, and will take
commenters' insights and recommendations into account moving forward.
I. Background
A. Historical Overview of the IRF PPS
Section 1886(j) of the Act provides for the implementation of a
per-discharge prospective payment system (PPS) for inpatient
rehabilitation hospitals and inpatient rehabilitation units of a
hospital (collectively, hereinafter referred to as IRFs). Payments
under the IRF PPS encompass inpatient operating and capital costs of
furnishing covered rehabilitation services (that is, routine,
ancillary, and capital costs), but not direct graduate medical
education costs, costs of approved nursing and allied health education
activities, bad debts, and other services or items outside the scope of
the IRF PPS. Although a complete discussion of the IRF PPS provisions
appears in the original FY 2002 IRF PPS final rule (66 FR 41316) and
the FY 2006 IRF PPS final rule (70 FR 47880), we are providing a
general description of the IRF PPS for FYs 2002 through 2018.
Under the IRF PPS from FY 2002 through FY 2005, the prospective
payment rates were computed across 100 distinct case-mix groups (CMGs),
as described in the FY 2002 IRF PPS final rule (66 FR 41316). We
constructed 95 CMGs using rehabilitation impairment categories (RICs),
functional status (both motor and cognitive), and age (in some cases,
cognitive status and age may not be a factor in defining a CMG). In
addition, we constructed five special CMGs to account for very short
stays and for patients who expire in the IRF.
For each of the CMGs, we developed relative weighting factors to
account for a patient's clinical characteristics and expected resource
needs. Thus, the weighting factors accounted for the relative
difference in resource use across all CMGs. Within each CMG, we created
tiers based on the estimated effects that certain comorbidities would
have on resource use.
We established the federal PPS rates using a standardized payment
conversion factor (formerly referred to as the budget-neutral
conversion factor). For a detailed discussion of the budget-neutral
conversion factor, please refer to our FY 2004 IRF PPS final rule (68
FR 45684 through 45685). In the FY 2006 IRF PPS final rule (70 FR
47880), we discussed in detail the methodology for determining the
standard payment conversion factor.
We applied the relative weighting factors to the standard payment
conversion factor to compute the unadjusted prospective payment rates
under the IRF PPS from FYs 2002 through 2005. Within the structure of
the payment system, we then made adjustments to account for interrupted
stays, transfers, short stays, and deaths. Finally, we applied the
applicable adjustments to account for geographic variations in wages
(wage index), the percentage of low-income patients, location in a
rural area (if applicable), and outlier payments (if applicable) to the
IRFs' unadjusted prospective payment rates.
For cost reporting periods that began on or after January 1, 2002,
and before October 1, 2002, we determined the final prospective payment
amounts using the transition methodology prescribed in section
1886(j)(1) of the Act. Under this provision, IRFs transitioning into
the PPS were paid a blend of the federal IRF PPS rate and the payment
that the IRFs would have received had the IRF PPS not been implemented.
This provision also allowed IRFs to elect to bypass this blended
payment and immediately be paid 100 percent of the federal IRF PPS
rate. The transition methodology expired as of cost reporting periods
beginning on or after October 1, 2002 (FY 2003), and payments for all
IRFs now consist of 100 percent of the federal IRF PPS rate.
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We established a CMS website as a primary information resource for
the IRF PPS which is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/index.html. The website
may be accessed to download or view publications, software, data
specifications, educational materials, and other information pertinent
to the IRF PPS.
Section 1886(j) of the Act confers broad statutory authority upon
the Secretary to propose refinements to the IRF PPS. In the FY 2006 IRF
PPS final rule (70 FR 47880) and in correcting amendments to the FY
2006 IRF PPS final rule (70 FR 57166) that we published on September
30, 2005, we finalized a number of refinements to the IRF PPS case-mix
classification system (the CMGs and the corresponding relative weights)
and the case-level and facility-level adjustments. These refinements
included the adoption of the Office of Management and Budget's (OMB)
Core-Based Statistical Area (CBSA) market definitions, modifications to
the CMGs, tier comorbidities, and CMG relative weights, implementation
of a new teaching status adjustment for IRFs, rebasing and revising the
market basket index used to update IRF payments, and updates to the
rural, low-income percentage (LIP), and high-cost outlier adjustments.
Beginning with the FY 2006 IRF PPS final rule (70 FR 47908 through
47917), the market basket index used to update IRF payments was a
market basket reflecting the operating and capital cost structures for
freestanding IRFs, freestanding inpatient psychiatric facilities
(IPFs), and long-term care hospitals (LTCHs) (hereinafter referred to
as the rehabilitation, psychiatric, and long-term care (RPL) market
basket). Any reference to the FY 2006 IRF PPS final rule in this final
rule also includes the provisions effective in the correcting
amendments. For a detailed discussion of the final key policy changes
for FY 2006, please refer to the FY 2006 IRF PPS final rule (70 FR
47880 and 70 FR 57166).
In the FY 2007 IRF PPS final rule (71 FR 48354), we further refined
the IRF PPS case-mix classification system (the CMG relative weights)
and the case-level adjustments, to ensure that IRF PPS payments would
continue to reflect as accurately as possible the costs of care. For a
detailed discussion of the FY 2007 policy revisions, please refer to
the FY 2007 IRF PPS final rule (71 FR 48354).
In the FY 2008 IRF PPS final rule (72 FR 44284), we updated the
prospective payment rates and the outlier threshold, revised the IRF
wage index policy, and clarified how we determine high-cost outlier
payments for transfer cases. For more information on the policy changes
implemented for FY 2008, please refer to the FY 2008 IRF PPS final rule
(72 FR 44284), in which we published the final FY 2008 IRF prospective
payment rates.
After publication of the FY 2008 IRF PPS final rule (72 FR 44284),
section 115 of the Medicare, Medicaid, and SCHIP Extension Act of 2007
(Pub. L. 110-173, enacted on December 29, 2007) (MMSEA) amended section
1886(j)(3)(C) of the Act to apply a zero percent increase factor for
FYs 2008 and 2009, effective for IRF discharges occurring on or after
April 1, 2008. Section 1886(j)(3)(C) of the Act required the Secretary
to develop an increase factor to update the IRF prospective payment
rates for each FY. Based on the legislative change to the increase
factor, we revised the FY 2008 prospective payment rates for IRF
discharges occurring on or after April 1, 2008. Thus, the final FY 2008
IRF prospective payment rates that were published in the FY 2008 IRF
PPS final rule (72 FR 44284) were effective for discharges occurring on
or after October 1, 2007, and on or before March 31, 2008, and the
revised FY 2008 IRF prospective payment rates were effective for
discharges occurring on or after April 1, 2008, and on or before
September 30, 2008. The revised FY 2008 prospective payment rates are
available on the CMS website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html.
In the FY 2009 IRF PPS final rule (73 FR 46370), we updated the CMG
relative weights, the average length of stay values, and the outlier
threshold; clarified IRF wage index policies regarding the treatment of
``New England deemed'' counties and multi-campus hospitals; and revised
the regulation text in response to section 115 of the MMSEA to set the
IRF compliance percentage at 60 percent (the ``60 percent rule'') and
continue the practice of including comorbidities in the calculation of
compliance percentages. We also applied a zero percent market basket
increase factor for FY 2009 in accordance with section 115 of the
MMSEA. For more information on the policy changes implemented for FY
2009, please refer to the FY 2009 IRF PPS final rule (73 FR 46370), in
which we published the final FY 2009 IRF prospective payment rates.
In the FY 2010 IRF PPS final rule (74 FR 39762) and in correcting
amendments to the FY 2010 IRF PPS final rule (74 FR 50712) that we
published on October 1, 2009, we updated the prospective payment rates,
the CMG relative weights, the average length of stay values, the rural,
LIP, teaching status adjustment factors, and the outlier threshold;
implemented new IRF coverage requirements for determining whether an
IRF claim is reasonable and necessary; and revised the regulation text
to require IRFs to submit patient assessments on Medicare Advantage
(MA) (formerly called Medicare Part C) patients for use in the 60
percent rule calculations. Any reference to the FY 2010 IRF PPS final
rule in this final rule also includes the provisions effective in the
correcting amendments. For more information on the policy changes
implemented for FY 2010, please refer to the FY 2010 IRF PPS final rule
(74 FR 39762 and 74 FR 50712), in which we published the final FY 2010
IRF prospective payment rates.
After publication of the FY 2010 IRF PPS final rule (74 FR 39762),
section 3401(d) of the Patient Protection and Affordable Care Act (Pub.
L. 111-148, enacted on March 23, 2010), as amended by section 10319 of
the same Act and by section 1105 of the Health Care and Education
Reconciliation Act of 2010 (Pub. L. 111-152, enacted on March 30, 2010)
(collectively, hereinafter referred to as ``PPACA''), amended section
1886(j)(3)(C) of the Act and added section 1886(j)(3)(D) of the Act.
Section 1886(j)(3)(C) of the Act requires the Secretary to estimate a
multifactor productivity (MFP) adjustment to the market basket increase
factor, and to apply other adjustments as defined by the Act. The
productivity adjustment applies to FYs from 2012 forward. The other
adjustments apply to FYs 2010 to 2019.
Sections 1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(i) of the Act
defined the adjustments that were to be applied to the market basket
increase factors in FYs 2010 and 2011. Under these provisions, the
Secretary was required to reduce the market basket increase factor in
FY 2010 by a 0.25 percentage point adjustment. Notwithstanding this
provision, in accordance with section 3401(p) of the PPACA, the
adjusted FY 2010 rate was only to be applied to discharges occurring on
or after April 1, 2010. Based on the self-implementing legislative
changes to section 1886(j)(3) of the Act, we adjusted the FY 2010
federal prospective payment rates as required, and applied these rates
to IRF discharges occurring on or after April 1, 2010, and on or before
September 30, 2010. Thus, the final FY 2010 IRF prospective payment
rates that were published in the FY 2010 IRF PPS final rule (74 FR
39762) were used for
[[Page 38518]]
discharges occurring on or after October 1, 2009, and on or before
March 31, 2010, and the adjusted FY 2010 IRF prospective payment rates
applied to discharges occurring on or after April 1, 2010, and on or
before September 30, 2010. The adjusted FY 2010 prospective payment
rates are available on the CMS website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html.
In addition, sections 1886(j)(3)(C) and (D) of the Act also
affected the FY 2010 IRF outlier threshold amount because they required
an adjustment to the FY 2010 RPL market basket increase factor, which
changed the standard payment conversion factor for FY 2010.
Specifically, the original FY 2010 IRF outlier threshold amount was
determined based on the original estimated FY 2010 RPL market basket
increase factor of 2.5 percent and the standard payment conversion
factor of $13,661. However, as adjusted, the IRF prospective payments
are based on the adjusted RPL market basket increase factor of 2.25
percent and the revised standard payment conversion factor of $13,627.
To maintain estimated outlier payments for FY 2010 equal to the
established standard of 3 percent of total estimated IRF PPS payments
for FY 2010, we revised the IRF outlier threshold amount for FY 2010
for discharges occurring on or after April 1, 2010, and on or before
September 30, 2010. The revised IRF outlier threshold amount for FY
2010 was $10,721.
Sections 1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(i) of the Act also
required the Secretary to reduce the market basket increase factor in
FY 2011 by a 0.25 percentage point adjustment. The FY 2011 IRF PPS
notice (75 FR 42836) and the correcting amendments to the FY 2011 IRF
PPS notice (75 FR 70013) described the required adjustments to the FY
2010 and FY 2011 IRF PPS prospective payment rates and outlier
threshold amount for IRF discharges occurring on or after April 1,
2010, and on or before September 30, 2011. It also updated the FY 2011
prospective payment rates, the CMG relative weights, and the average
length of stay values. Any reference to the FY 2011 IRF PPS notice in
this final rule also includes the provisions effective in the
correcting amendments. For more information on the FY 2010 and FY 2011
adjustments or the updates for FY 2011, please refer to the FY 2011 IRF
PPS notice (75 FR 42836 and 75 FR 70013).
In the FY 2012 IRF PPS final rule (76 FR 47836), we updated the IRF
prospective payment rates, rebased and revised the RPL market basket,
and established a new quality reporting program (QRP) for IRFs in
accordance with section 1886(j)(7) of the Act. We also consolidated,
clarified, and revised existing policies regarding IRF hospitals and
IRF units of hospitals to eliminate unnecessary confusion and enhance
consistency. For more information on the policy changes implemented for
FY 2012, please refer to the FY 2012 IRF PPS final rule (76 FR 47836),
in which we published the final FY 2012 IRF prospective payment rates.
The FY 2013 IRF PPS notice (77 FR 44618) described the required
adjustments to the FY 2013 prospective payment rates and outlier
threshold amount for IRF discharges occurring on or after October 1,
2012, and on or before September 30, 2013. It also updated the FY 2013
prospective payment rates, the CMG relative weights, and the average
length of stay values. For more information on the updates for FY 2013,
please refer to the FY 2013 IRF PPS notice (77 FR 44618).
In the FY 2014 IRF PPS final rule (78 FR 47860), we updated the
prospective payment rates, the CMG relative weights, and the outlier
threshold amount. We also updated the facility-level adjustment factors
using an enhanced estimation methodology, revised the list of diagnosis
codes that count toward an IRF's 60 percent rule compliance calculation
to determine ``presumptive compliance,'' revised sections of the
inpatient rehabilitation facility patient assessment instrument (IRF-
PAI), revised requirements for acute care hospitals that have IRF
units, clarified the IRF regulation text regarding limitation of
review, updated references to previously changed sections in the
regulations text, and updated requirements for the IRF QRP. For more
information on the policy changes implemented for FY 2014, please refer
to the FY 2014 IRF PPS final rule (78 FR 47860), in which we published
the final FY 2014 IRF prospective payment rates.
In the FY 2015 IRF PPS final rule (79 FR 45872), we updated the
prospective payment rates, the CMG relative weights, and the outlier
threshold amount. We also revised the list of diagnosis codes that
count toward an IRF's 60 percent rule compliance calculation to
determine ``presumptive compliance,'' revised sections of the IRF-PAI,
and updated requirements for the IRF QRP. For more information on the
policy changes implemented for FY 2015, please refer to the FY 2015 IRF
PPS final rule (79 FR 45872) and the FY 2015 IRF PPS correction notice
(79 FR 59121).
In the FY 2016 IRF PPS final rule (80 FR 47036), we updated the
prospective payment rates, the CMG relative weights, and the outlier
threshold amount. We also adopted an IRF-specific market basket that
reflects the cost structures of only IRF providers, a blended 1-year
transition wage index based on the adoption of new OMB area
delineations, a 3-year phase-out of the rural adjustment for certain
IRFs due to the new OMB area delineations, and updates for the IRF QRP.
For more information on the policy changes implemented for FY 2016,
please refer to the FY 2016 IRF PPS final rule (80 FR 47036).
In the FY 2017 IRF PPS final rule (81 FR 52056), we updated the
prospective payment rates, the CMG relative weights, and the outlier
threshold amount. We also updated requirements for the IRF QRP. For
more information on the policy changes implemented for FY 2017, please
refer to the FY 2017 IRF PPS final rule (81 FR 52056) and the FY 2017
IRF PPS correction notice (81 FR 59901).
In the FY 2018 IRF PPS final rule (82 FR 36238), we updated the
prospective payment rates, the CMG relative weights, and the outlier
threshold amount. We also revised the International Classification of
Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis
codes that are used to determine presumptive compliance under the ``60
percent rule,'' removed the 25 percent payment penalty for IRF-PAI late
transmissions, removed the voluntary swallowing status item (Item 27)
from the IRF-PAI, summarized comments regarding the criteria used to
classify facilities for payment under the IRF PPS, provided for a
subregulatory process for certain annual updates to the presumptive
methodology diagnosis code lists, adopted the use of height/weight
items on the IRF-PAI to determine patient body mass index (BMI) greater
than 50 for cases of single-joint replacement under the presumptive
methodology, and updated requirements for the IRF QRP. For more
information on the policy changes implemented for FY 2018, please refer
to the FY 2018 IRF PPS final rule (82 FR 36238).
B. Provisions of the PPACA Affecting the IRF PPS in FY 2012 and Beyond
The PPACA included several provisions that affect the IRF PPS in
FYs 2012 and beyond. In addition to what was previously discussed,
section 3401(d) of the PPACA also added section 1886(j)(3)(C)(ii)(I) of
the Act (providing for a ``productivity adjustment'' for fiscal year
2012 and
[[Page 38519]]
each subsequent fiscal year). The productivity adjustment for FY 2019
is discussed in section VI.B. of this final rule. Section 3401(d) of
the PPACA requires an additional 0.75 percentage point adjustment to
the IRF increase factor for each of FYs 2017, 2018, and 2019. The
applicable adjustment for FY 2019 is discussed in section VI.B. of this
final rule. Section 1886(j)(3)(C)(ii)(II) of the Act provides that the
application of these adjustments to the market basket update may result
in an update that is less than 0.0 for a fiscal year and in payment
rates for a fiscal year being less than such payment rates for the
preceding fiscal year.
Sections 3004(b) of the PPACA and section 411(b) of the Medicare
Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10, enacted on
April 16, 2015) (MACRA) also addressed the IRF PPS. Section 3004(b) of
PPACA reassigned the previously designated section 1886(j)(7) of the
Act to section 1886(j)(8) of the Act and inserted a new section
1886(j)(7) of the Act, which contains requirements for the Secretary to
establish a QRP for IRFs. Under that program, data must be submitted in
a form and manner and at a time specified by the Secretary. Section
411(b) of MACRA amended section 1886(j)(3)(C) of the Act by adding
clause (iii), which required us to apply for FY 2018, after the
application of section 1886(j)(3)(C)(ii) of the Act, an increase factor
of 1.0 percent to update the IRF prospective payment rates. Beginning
in FY 2014, section 1886(j)(7)(A)(i) of the Act requires the
application of a 2 percentage point reduction to the market basket
increase factor otherwise applicable to an IRF (after application of
subparagraphs (C)(iii) and (D) of section 1886(j)(3) of the Act) for a
fiscal year if the IRF does not comply with the requirements of the IRF
QRP for that fiscal year. Application of the 2 percentage point
reduction may result in an update that is less than 0.0 for a fiscal
year and in payment rates for a fiscal year being less than such
payment rates for the preceding fiscal year. Reporting-based reductions
to the market basket increase factor are not cumulative; they only
apply for the FY involved.
C. Operational Overview of the Current IRF PPS
As described in the FY 2002 IRF PPS final rule (66 FR 41316), upon
the admission and discharge of a Medicare Part A Fee-for-Service (FFS)
patient, the IRF is required to complete the appropriate sections of a
patient assessment instrument (PAI), designated as the IRF-PAI. In
addition, beginning with IRF discharges occurring on or after October
1, 2009, the IRF is also required to complete the appropriate sections
of the IRF-PAI upon the admission and discharge of each Medicare
Advantage (MA) patient, as described in the FY 2010 IRF PPS final rule
(74 FR 39762 and 74 FR 50712). All required data must be electronically
encoded into the IRF-PAI software product. Generally, the software
product includes patient classification programming called the Grouper
software. The Grouper software uses specific IRF-PAI data elements to
classify (or group) patients into distinct CMGs and account for the
existence of any relevant comorbidities.
The Grouper software produces a five-character CMG number. The
first character is an alphabetic character that indicates the
comorbidity tier. The last four characters are numeric characters that
represent the distinct CMG number. Free downloads of the Inpatient
Rehabilitation Validation and Entry (IRVEN) software product, including
the Grouper software, are available on the CMS website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Software.html.
Once a Medicare Part A FFS patient is discharged, the IRF submits a
Medicare claim as a Health Insurance Portability and Accountability Act
of 1996 (Pub. L. 104-191, enacted on August 21, 1996) (HIPAA) compliant
electronic claim or, if the Administrative Simplification Compliance
Act of 2002 (Pub. L. 107-105, enacted on December 27, 2002) (ASCA)
permits, a paper claim (a UB-04 or a CMS-1450 as appropriate) using the
five-character CMG number and sends it to the appropriate Medicare
Administrative Contractor (MAC). In addition, once a MA patient is
discharged, in accordance with the Medicare Claims Processing Manual,
chapter 3, section 20.3 (Pub. 100-04), hospitals (including IRFs) must
submit an informational-only bill (Type of Bill (TOB) 111), which
includes Condition Code 04 to their MAC. This will ensure that the MA
days are included in the hospital's Supplemental Security Income (SSI)
ratio (used in calculating the IRF LIP adjustment) for fiscal year 2007
and beyond. Claims submitted to Medicare must comply with both ASCA and
HIPAA.
Section 3 of the ASCA amended section 1862(a) of the Act by adding
paragraph (22), which requires the Medicare program, subject to section
1862(h) of the Act, to deny payment under Part A or Part B for any
expenses for items or services for which a claim is submitted other
than in an electronic form specified by the Secretary. Section 1862(h)
of the Act, in turn, provides that the Secretary shall waive such
denial in situations in which there is no method available for the
submission of claims in an electronic form or the entity submitting the
claim is a small provider. In addition, the Secretary also has the
authority to waive such denial in such unusual cases as the Secretary
finds appropriate. For more information, see the ``Medicare Program;
Electronic Submission of Medicare Claims'' final rule (70 FR 71008).
Our instructions for the limited number of Medicare claims submitted on
paper are available at http://www.cms.gov/manuals/downloads/clm104c25.pdf.
Section 3 of the ASCA operates in the context of the administrative
simplification provisions of HIPAA, which include, among others, the
requirements for transaction standards and code sets codified in 45
CFR, parts 160 and 162, subparts A and I through R (generally known as
the Transactions Rule). The Transactions Rule requires covered
entities, including covered health care providers, to conduct covered
electronic transactions according to the applicable transaction
standards. (See the CMS program claim memoranda at http://www.cms.gov/ElectronicBillingEDITrans/ and listed in the addenda to the Medicare
Intermediary Manual, Part 3, section 3600).
The MAC processes the claim through its software system. This
software system includes pricing programming called the ``Pricer''
software. The Pricer software uses the CMG number, along with other
specific claim data elements and provider-specific data, to adjust the
IRF's prospective payment for interrupted stays, transfers, short
stays, and deaths, and then applies the applicable adjustments to
account for the IRF's wage index, percentage of low-income patients,
rural location, and outlier payments. For discharges occurring on or
after October 1, 2005, the IRF PPS payment also reflects the teaching
status adjustment that became effective as of FY 2006, as discussed in
the FY 2006 IRF PPS final rule (70 FR 47880).
D. Advancing Health Information Exchange
The Department of Health and Human Services (HHS) has a number of
initiatives designed to encourage and support the adoption of
interoperable health information technology and to promote nationwide
health information exchange to improve health care. The Office of the
National Coordinator for
[[Page 38520]]
Health Information Technology (ONC) and CMS work collaboratively to
advance interoperability across settings of care, including post-acute
care.
The Improving Medicare Post-Acute Care Transformation Act of 2014
(Pub. L. 113-185, enacted on October 6, 2014) (IMPACT Act) requires
assessment data to be standardized and interoperable to allow for
exchange of the data among post-acute providers and other providers. To
further interoperability in post-acute care, CMS is developing a Data
Element Library to serve as a publically available centralized,
authoritative resource for standardized data elements and their
associated mappings to health IT standards. These interoperable data
elements can reduce provider burden by supporting the use and reuse of
healthcare data, support provider exchange of electronic health
information for care coordination, person-centered care, and support
real-time, data driven, clinical decision making. Once available,
standards in the Data Element Library can be referenced on the CMS
website and in the ONC Interoperability Standards Advisory (ISA).
The 2018 Interoperability Standards Advisory (ISA) is available at
https://www.healthit.gov/isa/.
Most recently, the 21st Century Cures Act (Pub. L. 114-255, enacted
on December 13, 2016) (Cures Act), requires HHS to take new steps to
enable the electronic sharing of health information ensuring
interoperability for providers and settings across the care continuum.
Specifically, Congress directed ONC to ``develop or support a trusted
exchange framework, including a common agreement among health
information networks nationally.'' This framework (https://beta.healthit.gov/topic/interoperability/trusted-exchange-framework-and-common-agreement) outlines a common set of principles for trusted
exchange and minimum terms and conditions for trusted exchange in order
to enable interoperability across disparate health information
networks. In another important provision, Congress defined
``information blocking'' as practices likely to interfere with,
prevent, or materially discourage access, exchange, or use of
electronic health information, and established new authority for HHS to
discourage these practices. We invite providers to learn more about
these important developments and how they are likely to affect IRFs.
II. Summary of Provisions of the Proposed Rule
In the FY 2019 IRF PPS proposed rule (83 FR 20972), we proposed to
update the IRF prospective payment rates for FY 2019 and to alleviate
administrative burden for IRFs by removing the FIMTM
instrument and associated Function Modifiers from the IRF-PAI in
accordance with section 1886(j)(2)(D) of the Act and revise certain IRF
coverage requirements to reduce the amount of required paperwork in the
IRF setting. In addition, we solicited comments on removing the face-
to-face requirement for rehabilitation physician visits and expanding
the use of non-physician practitioners (that is, nurse practitioners
and physician assistants) in meeting the IRF coverage requirements. For
the IRF QRP, we proposed to add a new quality measure removal factor,
remove two quality measures from the measure set, and codify in our
regulations a number of requirements.
The proposed updates to the IRF prospective payment rates for FY
2019 are as follows:
Update the IRF PPS relative weights and average length of
stay values for FY 2019 using the most current and complete Medicare
claims and cost report data in a budget-neutral manner, as discussed in
section III. of the FY 2019 IRF PPS proposed rule (83 FR 20972, 20978
through 20981).
Describe the continued use of FY 2014 facility-level
adjustment factors, as discussed in section IV. of the FY 2019 IRF PPS
proposed rule (83 FR 20972 at 20981).
Update the IRF PPS payment rates for FY 2019 by the market
basket increase factor, based upon the most current data available,
with a 0.75 percentage point reduction as required by sections
1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(v) of the Act and a
productivity adjustment required by section 1886(j)(3)(C)(ii)(I) of the
Act, as described in section V. of the FY 2019 IRF PPS proposed rule
(83 FR 20972 at 20982).
Update the FY 2019 IRF PPS payment rates by the FY 2019
wage index and the labor-related share in a budget-neutral manner, as
discussed in section V. of the FY 2019 IRF PPS proposed rule (83 FR
20972, 20982 through 20984).
Describe the calculation of the IRF standard payment
conversion factor for FY 2019, as discussed in section V. of the FY
2019 IRF PPS proposed rule (83 FR 20972, 20984 through 20985).
Update the outlier threshold amount for FY 2019, as
discussed in section VI. of the FY 2019 IRF PPS proposed rule (83 FR
20972 at 20987).
Update the cost-to-charge ratio (CCR) ceiling and urban/
rural average CCRs for FY 2019, as discussed in section VI. of the FY
2019 IRF PPS proposed rule (83 FR 20972, 20987 through 20988).
Remove the FIM\TM\ instrument and associated Function
Modifiers from the IRF-PAI beginning with FY 2020 to reduce
administrative burden for IRFs, as discussed in section VII. of the FY
2019 IRF PPS proposed rule (83 FR 20972, 20988 through 20995).
Revise certain IRF coverage requirements to reduce
administrative burden for IRFs beginning with FY 2019, as discussed in
section VIII. of the FY 2019 IRF PPS proposed rule (83 FR 20972, 20995
through 20997).
Solicit comments on removing the face-to-face requirement
for rehabilitation physician visits, as discussed in section VIII. of
the FY 2019 IRF PPS proposed rule (83 FR 20972, 20997 through 20998).
Solicit comments on expanding the use of non-physician
practitioners (that is, nurse practitioners and physician assistants)
in meeting the IRF coverage requirements, as discussed in section VIII.
of the FY 2019 IRF PPS proposed rule (83 FR 20972, 20998 through
20999).
Update the requirements for the IRF QRP, as discussed in
section IX. of the FY 2019 IRF PPS proposed rule (83 FR 20972, 20999
through 21004).
III. Analysis and Response to Public Comments
We received 109 timely responses from the public, many of which
contained multiple comments on the FY 2019 IRF PPS proposed rule (83 FR
20972). We received comments from various trade associations, inpatient
rehabilitation facilities, individual physicians, therapists,
clinicians, health care industry organizations, and health care
consulting firms. The following sections, arranged by subject area,
include a summary of the public comments that we received, and our
responses.
IV. Update to the Case-Mix Group (CMG) Relative Weights and Average
Length of Stay Values for FY 2019
As specified in Sec. 412.620(b)(1), we calculate a relative weight
for each CMG that is proportional to the resources needed by an average
inpatient rehabilitation case in that CMG. For example, cases in a CMG
with a relative weight of 2, on average, will cost twice as much as
cases in a CMG with a relative weight of 1. Relative weights account
for the variance in cost per discharge due to the variance in resource
utilization among the payment groups, and their use helps to ensure
that IRF PPS payments support
[[Page 38521]]
beneficiary access to care, as well as provider efficiency.
In the FY 2019 IRF PPS proposed rule (83 FR 20972, 20978 through
20981), we proposed to update the CMG relative weights and average
length of stay values for FY 2019. As required by statute, we always
use the most recent available data to update the CMG relative weights
and average lengths of stay. For FY 2019, we proposed to use the FY
2017 IRF claims and FY 2016 IRF cost report data. These data are the
most current and complete data available at this time. We note that, as
we typically do, we updated our data between the FY 2019 IRF PPS
proposed and final rules to ensure that we use the most recent
available data in calculating IRF PPS payments. This updated data
reflects a more complete set of claims for FY 2017 and additional cost
report data for FY 2016.
In the FY 2019 IRF PPS proposed rule, we proposed to apply these
data using the same methodologies that we have used to update the CMG
relative weights and average length of stay values each fiscal year
since we implemented an update to the methodology to use the more
detailed CCR data from the cost reports of IRF subprovider units of
primary acute care hospitals, instead of CCR data from the associated
primary care hospitals, to calculate IRFs' average costs per case, as
discussed in the FY 2009 IRF PPS final rule (73 FR 46372). In
calculating the CMG relative weights, we use a hospital-specific
relative value method to estimate operating (routine and ancillary
services) and capital costs of IRFs. The process used to calculate the
CMG relative weights for this final rule is as follows:
Step 1. We estimate the effects that comorbidities have on costs.
Step 2. We adjust the cost of each Medicare discharge (case) to
reflect the effects found in the first step.
Step 3. We use the adjusted costs from the second step to calculate
CMG relative weights, using the hospital-specific relative value
method.
Step 4. We normalize the FY 2019 CMG relative weights to the same
average CMG relative weight from the CMG relative weights implemented
in the FY 2018 IRF PPS final rule (82 FR 36238).
Consistent with the methodology that we have used to update the IRF
classification system in each instance in the past, we proposed to
update the CMG relative weights for FY 2019 in such a way that total
estimated aggregate payments to IRFs for FY 2019 are the same with or
without the changes (that is, in a budget-neutral manner) by applying a
budget neutrality factor to the standard payment amount. To calculate
the appropriate budget neutrality factor for use in updating the FY
2019 CMG relative weights, we use the following steps:
Step 1. Calculate the estimated total amount of IRF PPS payments
for FY 2019 (with no changes to the CMG relative weights).
Step 2. Calculate the estimated total amount of IRF PPS payments
for FY 2019 by applying the changes to the CMG relative weights (as
discussed in this final rule).
Step 3. Divide the amount calculated in step 1 by the amount
calculated in step 2 to determine the budget neutrality factor (0.9981)
that would maintain the same total estimated aggregate payments in FY
2019 with and without the changes to the CMG relative weights.
Step 4. Apply the budget neutrality factor (0.9981) to the FY 2018
IRF PPS standard payment amount after the application of the budget-
neutral wage adjustment factor.
In section VI.E. of this final rule, we discuss the use of the
existing methodology to calculate the standard payment conversion
factor for FY 2019.
In Table 2, ``Relative Weights and Average Length of Stay Values
for Case-Mix Groups,'' we present the CMGs, the comorbidity tiers, the
corresponding relative weights, and the average length of stay values
for each CMG and tier for FY 2019. The average length of stay for each
CMG is used to determine when an IRF discharge meets the definition of
a short-stay transfer, which results in a per diem case level
adjustment.
Table 2--Relative Weights and Average Length of Stay Values for Case-Mix Groups
--------------------------------------------------------------------------------------------------------------------------------------------------------
Relative weight Average length of stay
-----------------------------------------------------------------------------------------
CMG CMG description (M = motor, C = No No
cognitive, A = age) Tier 1 Tier 2 Tier 3 comorbidities Tier 1 Tier 2 Tier 3 comorbidities
tier tier
--------------------------------------------------------------------------------------------------------------------------------------------------------
0101........................ Stroke M > 51.05................ 0.8465 0.7365 0.6747 0.6451 8 11 9 8
0102........................ Stroke M > 44.45 and M < 51.05 1.0706 0.9315 0.8533 0.8159 11 12 10 10
and C > 18.5.
0103........................ Stroke M > 44.45 and M < 51.05 1.2391 1.0781 0.9876 0.9443 12 13 11 12
and C < 18.5.
0104........................ Stroke M > 38.85 and M < 44.45.. 1.2938 1.1257 1.0312 0.9860 12 13 12 12
0105........................ Stroke M > 34.25 and M < 38.85.. 1.4871 1.2938 1.1852 1.1333 14 14 14 13
0106........................ Stroke M > 30.05 and M < 34.25.. 1.6628 1.4467 1.3253 1.2673 16 16 15 15
0107........................ Stroke M > 26.15 and M < 30.05.. 1.8653 1.6229 1.4867 1.4216 18 18 16 16
0108........................ Stroke M < 26.15 and A > 84.5... 2.3056 2.0060 1.8376 1.7572 22 21 20 20
0109........................ Stroke M > 22.35 and M < 26.15 2.0857 1.8147 1.6624 1.5896 19 19 18 18
and A < 84.5.
0110........................ Stroke M < 22.35 and A < 84.5... 2.7655 2.4060 2.2041 2.1076 26 26 23 23
0201........................ Traumatic brain injury M > 53.35 0.8235 0.6628 0.5922 0.5527 9 9 8 7
and C > 23.5.
0202........................ Traumatic brain injury M > 44.25 1.1508 0.9263 0.8275 0.7724 10 11 10 10
and M < 53.35 and C > 23.5.
0203........................ Traumatic brain injury M > 44.25 1.2723 1.0240 0.9149 0.8539 13 13 11 10
and C < 23.5.
0204........................ Traumatic brain injury M > 40.65 1.3841 1.1141 0.9953 0.9290 13 13 11 11
and M < 44.25.
0205........................ Traumatic brain injury M > 28.75 1.6330 1.3143 1.1743 1.0960 14 15 13 13
and M < 40.65.
0206........................ Traumatic brain injury M > 22.05 1.9661 1.5825 1.4139 1.3196 18 18 15 15
and M < 28.75.
0207........................ Traumatic brain injury M < 22.05 2.4863 2.0012 1.7879 1.6687 30 22 19 18
0301........................ Non-traumatic brain injury M > 1.1727 0.9483 0.8703 0.8135 11 11 10 10
41.05.
0302........................ Non-traumatic brain injury M > 1.4347 1.1603 1.0648 0.9953 12 13 12 12
35.05 and M < 41.05.
0303........................ Non-traumatic brain injury M > 1.6572 1.3402 1.2300 1.1496 15 14 13 13
26.15 and M < 35.05.
0304........................ Non-traumatic brain injury M < 2.1203 1.7147 1.5737 1.4709 20 19 16 16
26.15.
0401........................ Traumatic spinal cord injury M > 1.0040 0.8097 0.7490 0.6855 10 10 9 9
48.45.
0402........................ Traumatic spinal cord injury M > 1.4873 1.1996 1.1096 1.0155 14 13 13 12
30.35 and M < 48.45.
0403........................ Traumatic spinal cord injury M > 2.3688 1.9105 1.7673 1.6175 25 22 19 18
16.05 and M < 30.35.
0404........................ Traumatic spinal cord injury M < 4.0377 3.2566 3.0125 2.7571 45 36 31 30
16.05 and A > 63.5.
0405........................ Traumatic spinal cord injury M < 3.6175 2.9177 2.6989 2.4701 26 35 29 26
16.05 and A > 63.5.
0501........................ Non-traumatic spinal cord injury 0.9171 0.7145 0.6605 0.6070 9 10 8 8
M > 51.35.
0502........................ Non-traumatic spinal cord injury 1.2182 0.9491 0.8774 0.8063 11 11 10 10
M > 40.15 and M < 51.35.
[[Page 38522]]
0503........................ Non-traumatic spinal cord injury 1.5156 1.1809 1.0916 1.0031 14 13 12 12
M > 31.25 and M < 40.15.
0504........................ Non-traumatic spinal cord injury 1.7426 1.3577 1.2551 1.1533 16 14 14 13
M > 29.25 and M < 31.25.
0505........................ Non-traumatic spinal cord injury 1.9957 1.5550 1.4374 1.3209 18 17 16 15
M > 23.75 and M < 29.25.
0506........................ Non-traumatic spinal cord injury 2.6996 2.1034 1.9443 1.7867 26 23 21 20
M < 23.75.
0601........................ Neurological M > 47.75.......... 1.0736 0.8242 0.7624 0.6948 9 9 9 8
0602........................ Neurological M > 37.35 and M < 1.3920 1.0686 0.9884 0.9008 12 12 11 10
47.75.
0603........................ Neurological M > 25.85 and M < 1.7124 1.3146 1.2159 1.1082 14 14 13 13
37.35.
0604........................ Neurological M < 25.85.......... 2.2148 1.7003 1.5727 1.4334 19 17 16 16
0701........................ Fracture of lower extremity M > 1.0280 0.8387 0.7948 0.7171 10 10 9 9
42.15.
0702........................ Fracture of lower extremity M > 1.3083 1.0674 1.0115 0.9127 12 12 12 11
34.15 and M < 42.15.
0703........................ Fracture of lower extremity M > 1.5600 1.2728 1.2062 1.0883 14 14 14 13
28.15 and M < 34.15.
0704........................ Fracture of lower extremity M < 1.9907 1.6242 1.5392 1.3888 18 18 17 16
28.15.
0801........................ Replacement of lower extremity 0.8391 0.6841 0.6185 0.5754 8 8 8 7
joint M > 49.55.
0802........................ Replacement of lower extremity 1.0766 0.8777 0.7936 0.7382 11 9 9 9
joint M > 37.05 and M < 49.55.
0803........................ Replacement of lower extremity 1.4123 1.1514 1.0410 0.9684 13 13 12 11
joint M > 28.65 and M < 37.05
and A > 83.5.
0804........................ Replacement of lower extremity 1.2727 1.0376 0.9381 0.8727 12 12 11 10
joint M > 28.65 and M < 37.05
and A > 83.5.
0805........................ Replacement of lower extremity 1.5169 1.2367 1.1181 1.0401 14 14 12 12
joint M > 22.05 and M < 28.65.
0806........................ Replacement of lower extremity 1.8691 1.5238 1.3777 1.2816 17 17 15 14
joint M < 22.05.
0901........................ Other orthopedic M > 44.75...... 1.0283 0.8073 0.7481 0.6894 11 10 9 8
0902........................ Other orthopedic M > 34.35 and M 1.3030 1.0230 0.9479 0.8736 12 12 11 10
< 44.75.
0903........................ Other orthopedic M > 24.15 and M 1.6262 1.2768 1.1831 1.0903 14 14 13 12
< 34.35.
0904........................ Other orthopedic M < 24.15...... 2.0372 1.5995 1.4821 1.3659 17 17 16 15
1001........................ Amputation, lower extremity M > 1.0941 0.9260 0.8226 0.7584 11 11 10 9
47.65.
1002........................ Amputation, lower extremity M > 1.3984 1.1835 1.0513 0.9693 13 13 12 12
36.25 and M < 47.65.
1003........................ Amputation, lower extremity M < 2.0247 1.7136 1.5222 1.4034 18 18 16 15
36.25.
1101........................ Amputation, non-lower extremity 1.3618 1.0044 1.0044 0.8832 12 11 11 11
M > 36.35.
1102........................ Amputation, non-lower extremity 1.9208 1.4167 1.4167 1.2458 17 15 15 13
M < 36.35.
1201........................ Osteoarthritis M > 37.65........ 1.1125 0.9541 0.8710 0.7877 11 10 10 9
1202........................ Osteoarthritis M > 30.75 and M < 1.4092 1.2085 1.1032 0.9978 13 13 12 12
37.65.
1203........................ Osteoarthritis M < 30.75........ 1.7067 1.4637 1.3361 1.2084 15 16 15 14
1301........................ Rheumatoid, other arthritis M > 1.0977 0.9523 0.8893 0.8342 10 10 10 10
36.35.
1302........................ Rheumatoid, other arthritis M > 1.4355 1.2454 1.1630 1.0909 12 13 13 12
26.15 and M < 36.35.
1303........................ Rheumatoid, other arthritis M < 1.7337 1.5041 1.4046 1.3175 14 17 15 15
26.15.
1401........................ Cardiac M > 48.85............... 0.9226 0.7511 0.6772 0.6103 9 8 8 7
1402........................ Cardiac M > 38.55 and M < 48.85. 1.2379 1.0079 0.9086 0.8189 11 11 10 10
1403........................ Cardiac M > 31.15 and M < 38.55. 1.4752 1.2011 1.0828 0.9759 13 13 12 11
1404........................ Cardiac M < 31.15............... 1.8581 1.5129 1.3639 1.2292 17 16 15 13
1501........................ Pulmonary M > 49.25............. 1.0145 0.8753 0.7927 0.7596 9 10 9 8
1502........................ Pulmonary M > 39.05 and M < 1.2970 1.1191 1.0134 0.9711 11 11 10 11
49.25.
1503........................ Pulmonary M > 29.15 and M < 1.5391 1.3280 1.2026 1.1524 14 13 12 12
39.05.
1504........................ Pulmonary M < 29.15............. 1.9395 1.6735 1.5155 1.4522 19 16 15 14
1601........................ Pain syndrome M > 37.15......... 1.2123 0.9280 0.8814 0.7954 9 11 10 10
1602........................ Pain syndrome M > 26.75 and M < 1.5361 1.1758 1.1169 1.0079 11 12 12 12
37.15.
1603........................ Pain syndrome M < 26.75......... 1.8637 1.4266 1.3551 1.2228 12 16 15 14
1701........................ Major multiple trauma without 1.2825 0.9724 0.9103 0.8196 14 11 10 10
brain or spinal cord injury M >
39.25.
1702........................ Major multiple trauma without 1.5510 1.1760 1.1009 0.9912 14 14 12 11
brain or spinal cord injury M >
31.05 and M < 39.25.
1703........................ Major multiple trauma without 1.8097 1.3722 1.2846 1.1565 15 15 14 13
brain or spinal cord injury M >
25.55 and M < 31.05.
1704........................ Major multiple trauma without 2.3097 1.7513 1.6395 1.4761 20 19 17 16
brain or spinal cord injury M <
25.55.
1801........................ Major multiple trauma with brain 1.1285 1.0063 0.8504 0.7943 12 11 10 10
or spinal cord injury M > 40.85.
1802........................ Major multiple trauma with brain 1.6639 1.4838 1.2539 1.1712 16 17 14 13
or spinal cord injury M > 23.05
and M < 40.85.
1803........................ Major multiple trauma with brain 2.6145 2.3315 1.9703 1.8403 30 25 20 19
or spinal cord injury M < 23.05.
1901........................ Guillain Barre M > 35.95........ 1.4000 1.0049 0.9440 0.9096 15 13 11 11
1902........................ Guillain Barre M > 18.05 and M < 2.4651 1.7694 1.6622 1.6017 24 21 18 18
35.95.
1903........................ Guillain Barre M < 18.05........ 4.2669 3.0627 2.8772 2.7725 46 31 30 30
2001........................ Miscellaneous M > 49.15......... 0.9693 0.7709 0.7160 0.6500 9 9 8 8
2002........................ Miscellaneous M > 38.75 and M < 1.2597 1.0018 0.9306 0.8448 12 11 10 10
49.15.
2003........................ Miscellaneous M > 27.85 and M < 1.5484 1.2314 1.1438 1.0384 14 14 12 12
38.75.
2004........................ Miscellaneous M < 27.85......... 1.9734 1.5695 1.4578 1.3234 18 17 15 15
2101........................ Burns M > 0..................... 1.9075 1.5493 1.4963 1.3168 22 16 16 14
5001........................ Short-stay cases, length of stay ........ ........ ........ 0.1599 ........ ........ ........ 2
is 3 days or fewer.
5101........................ Expired, orthopedic, length of ........ ........ ........ 0.7539 ........ ........ ........ 8
stay is 13 days or fewer.
5102........................ Expired, orthopedic, length of ........ ........ ........ 1.6493 ........ ........ ........ 18
stay is 14 days or more.
5103........................ Expired, not orthopedic, length ........ ........ ........ 0.8091 ........ ........ ........ 8
of stay is 15 days or fewer.
[[Page 38523]]
5104........................ Expired, not orthopedic, length ........ ........ ........ 2.1145 ........ ........ ........ 21
of stay is 16 days or more.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Generally, updates to the CMG relative weights result in some
increases and some decreases to the CMG relative weight values. Table 3
shows how we estimate that the application of the revisions for FY 2019
would affect particular CMG relative weight values, which would affect
the overall distribution of payments within CMGs and tiers. Note that,
because we proposed to implement the CMG relative weight revisions in a
budget-neutral manner (as previously described), total estimated
aggregate payments to IRFs for FY 2019 would not be affected as a
result of the CMG relative weight revisions. However, the revisions
would affect the distribution of payments within CMGs and tiers.
Table 3--Distributional Effects of the Changes to the CMG Relative
Weights
[FY 2018 values compared with FY 2019 values]
------------------------------------------------------------------------
Percentage change in CMG relative Number of Percentage of
weights cases affected cases affected
------------------------------------------------------------------------
Increased by 15% or more................ 19 0.0
Increased by between 5% and 15%......... 1,634 0.4
Changed by less than 5%................. 397,675 99.3
Decreased by between 5% and 15%......... 1,160 0.3
Decreased by 15% or more................ 73 0.0
------------------------------------------------------------------------
As Table 3 shows, 99.3 percent of all IRF cases are in CMGs and
tiers that would experience less than a 5 percent change (either
increase or decrease) in the CMG relative weight value as a result of
the revisions for FY 2019. The largest estimated increase in the CMG
relative weight values that affects the largest number of IRF
discharges would be a 3.4 percent change in the CMG relative weight
value for CMG 0806 Replacement of lower extremity joint, with a motor
score less than 22.05 --with no tier adjustment. In the FY 2017 claims
data, 1,593 IRF discharges (0.4 percent of all IRF discharges) were
classified into this CMG and tier.
The largest estimated decrease in a CMG relative weight value
affecting the largest number of IRF cases would be a 2.1 percent
decrease in the CMG relative weight for CMG 0304--Non-traumatic brain
injury, with a motor score less than 26.5--with no tier adjustment. In
the FY 2017 IRF claims data, this change would have affected 3,388
cases (0.8 percent of all IRF cases).
The proposed changes in the average length of stay values for FY
2019, compared with the FY 2018 average length of stay values, are
small and do not show any particular trends in IRF length of stay
patterns.
We received 1 comment on the proposed update to the CMG relative
weights and average length of stay values for FY 2019, which is
summarized below.
Comment: The commenter was supportive of our proposal to use the
most recent data available to update the relative weights and average
length of stays values for FY 2019. The commenter also requested that
CMS make available any reports and analyses that we used to update the
relative weights and average length of stay values.
Response: We appreciate the commenter's support of our proposal to
use the most recent data available to update the relative weights and
average length of stays values for FY 2019. For reports on the
methodology that we use annually to update the relative weights and
average length of stay values, we refer stakeholders to reports issued
by the RAND Corporation (RAND) for the implementation of the IRF PPS,
which can be downloaded from RAND's website at https://www.rand.org/pubs/drafts/DRU2309.html and at https://www.rand.org/pubs/monograph_reports/MR1500.html. We also refer stakeholders to a report
that was issued by RAND in 2005 that specifically discusses the
methodology for construction of the CMGs and the relative weights
associated with the CMGs, which can be downloaded from RAND's website
at https://www.rand.org/pubs/technical_reports/TR207.html. We used the
same methodology, with one exception, that RAND used in these reports
to calculate the CMG relative weights and average length of stay
values. For a specific discussion of the change in our methodology that
we implemented in FY 2009, we refer stakeholders to the FY 2009 IRF PPS
final rule (73 FR 46372).
Final Decision: After consideration of the public comments, we are
finalizing our proposal to update the CMG relative weight and average
length of stay values for FY 2019, as shown in Table 2 of this final
rule. These updates are effective October 1, 2018.
V. Facility-Level Adjustment Factors
Section 1886(j)(3)(A)(v) of the Act confers broad authority upon
the Secretary to adjust the per unit payment rate by such factors as
the Secretary determines are necessary to properly reflect variations
in necessary costs of treatment among rehabilitation facilities. Under
this authority, we currently adjust the prospective payment amount
associated with a CMG to account for facility-level characteristics
such as an IRF's LIP, teaching status, and location in a rural area, if
applicable, as described in Sec. 412.624(e).
Based on the substantive changes to the facility-level adjustment
factors that were adopted in the FY IRF PPS 2014 final rule (78 FR
47860, 47868 through 47872), in the FY 2015 IRF PPS final rule (79 FR
45872, 45882 through 45883), we froze the facility-level adjustment
factors at the FY 2014 levels for FY 2015 and all subsequent years
[[Page 38524]]
(unless and until we propose to update them again through future
notice-and-comment rulemaking). For FY 2019, we will continue to hold
the adjustment factors at the FY 2014 levels as we continue to monitor
the most current IRF claims data available and continue to evaluate and
monitor the effects of the FY 2014 changes.
VI. FY 2019 IRF PPS Payment Update
A. Background
Section 1886(j)(3)(C) of the Act requires the Secretary to
establish an increase factor that reflects changes over time in the
prices of an appropriate mix of goods and services included in the IRF
PPS payment, which is referred to as a market basket index. According
to section 1886(j)(3)(A)(i) of the Act, the increase factor shall be
used to update the IRF prospective payment rates for each FY. Section
1886(j)(3)(C)(ii)(I) of the Act requires the application of a
productivity adjustment. In addition, sections 1886(j)(3)(C)(ii)(II)
and 1886(j)(3)(D)(v) of the Act require the application of a 0.75
percentage point reduction to the market basket increase factor for FY
2019. Thus, in the FY 2019 IRF proposed rule (83 FR 20981), we proposed
to update the IRF PPS payments for FY 2019 by a market basket increase
factor as required by section 1886(j)(3)(C) of the Act, with a
productivity adjustment as required by section 1886(j)(3)(C)(ii)(I) of
the Act, and a 0.75 percentage point reduction as required by sections
1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(v) of the Act.
Beginning with the FY 2016 IRF PPS, we created and adopted a stand-
alone IRF market basket, which was referred to as the 2012-based IRF
market basket, reflecting the operating and capital cost structures for
freestanding IRFs and hospital-based IRFs. The FY 2016 IRF PPS final
rule (80 FR 47046 through 47068) contains a complete discussion of the
development of the 2012-based IRF market basket.
B. FY 2019 Market Basket Update and Productivity Adjustment
For FY 2018, we applied an increase factor of 1.0 percent to update
the IRF prospective payment rates in accordance with section
1886(j)(3)(C)(iii) of the Act, as added by section 411(b) of MACRA.
However, as discussed previously, for FY 2019, we proposed to update
the IRF PPS payments by a market basket increase factor as required by
section 1886(j)(3)(C) of the Act, with a productivity adjustment as
required by section 1886(j)(3)(C)(ii)(I) of the Act, and a 0.75
percentage point reduction as required by sections
1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(v) of the Act. For FY 2019, we
proposed to use the same methodology described in the FY 2017 IRF PPS
final rule (81 FR 52071) to compute the FY 2019 market basket increase
factor to update the IRF PPS base payment rate.
Consistent with historical practice, we proposed to estimate the
market basket update for the IRF PPS based on the most up-to-date
forecast of price indexes used in the market basket as forecasted by
IHS Global Inc. (IGI). IGI is a nationally recognized economic and
financial forecasting firm with which we contract to forecast the
components of the market baskets and MFP. Based on IGI's first quarter
2018 forecast with historical data through the fourth quarter of 2017,
we proposed that the projected 2012-based IRF market basket increase
factor for FY 2019 would be 2.9 percent. We also proposed that if more
recent data were subsequently available (for example, a more recent
estimate of the market basket update), we would use such data to
determine the FY 2019 market basket update in the final rule.
Incorporating the most recent data available, based on IGI's second
quarter 2018 forecast with historical data through the first quarter of
2018, the projected 2012-based IRF market basket increase factor for FY
2019 is 2.9 percent.
According to section 1886(j)(3)(C)(i) of the Act, the Secretary
shall establish an increase factor based on an appropriate percentage
increase in a market basket of goods and services. Section
1886(j)(3)(C)(ii) of the Act then requires that, after establishing the
increase factor for a FY, the Secretary shall reduce such increase
factor for FY 2012 and each subsequent FY, by the productivity
adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act.
Section 1886(b)(3)(B)(xi)(II) of the Act sets forth the definition of
this productivity adjustment. The statute defines the productivity
adjustment to be equal to the 10-year moving average of changes in
annual economy-wide private nonfarm business multifactor productivity
(MFP) (as projected by the Secretary for the 10-year period ending with
the applicable FY, year, cost reporting period, or other annual period)
(the ``MFP adjustment''). The BLS publishes the official measure of
private nonfarm business MFP. Please see http://www.bls.gov/mfp for the
BLS historical published MFP data. A complete description of the MFP
projection methodology is available on the CMS website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/MarketBasketResearch.html.
Using IGI's first quarter 2018 forecast, the projected MFP
adjustment for FY 2019 (the 10-year moving average of MFP for the
period ending FY 2019) was 0.8 percent. We proposed that if more recent
data were subsequently available, we would use such data to determine
the FY 2019 MFP adjustment in the final rule. Incorporating the most
recent data available, based on IGI's second quarter 2018 forecast, the
projected MFP adjustment for FY 2019 is 0.8 percent.
Thus, in accordance with section 1886(j)(3)(C) of the Act, we
proposed to base the FY 2019 market basket update, which is used to
determine the applicable percentage increase for the IRF payments, on
the most recent estimate of the 2012-based IRF market basket. We
proposed to then reduce this percentage increase by the most recent
estimate of the MFP adjustment for FY 2019. Following application of
the MFP adjustment, we proposed to further reduce the applicable
percentage increase by 0.75 percentage point, as required by sections
1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(v) of the Act. Therefore, the
proposed FY 2019 IRF update was 1.35 percent (2.9 percent market basket
update, less 0.8 percentage point MFP adjustment, less 0.75 percentage
point statutorily required adjustment). Furthermore, we proposed that
if more recent data were subsequently available (for example, a more
recent estimate of the MFP adjustment), we would use such data to
determine the FY 2019 MFP adjustment in the final rule. Incorporating
the most recent data, the current estimate of the FY 2019 IRF update is
1.35 percent (2.9 percent market basket update, less 0.8 percentage
point MFP adjustment, less 0.75 percentage point statutorily required
adjustment).
For FY 2019, the Medicare Payment Advisory Commission (MedPAC)
recommends that we reduce IRF PPS payment rates by 5 percent. As
discussed, and in accordance with sections 1886(j)(3)(C) and
1886(j)(3)(D) of the Act, the Secretary proposed to update the IRF PPS
payment rates for FY 2019 by an adjusted market basket increase factor
of 1.35 percent, as section 1886(j)(3)(C) of the Act does not provide
the Secretary with the authority to apply a different update factor to
IRF PPS payment rates for FY 2019. As noted above, incorporating the
most recent data, the current estimate of the FY 2019 IRF update is
1.35 percent.
We received 4 comments on the proposed market basket increase
update and productivity adjustment, which are summarized below.
[[Page 38525]]
Comment: One commenter noted that they generally concur with the
methodology CMS has used to arrive at the proposed net market basket
update of 1.35 percent and encouraged CMS to use the latest available
information to update this market basket percentage in the final rule.
Response: We appreciate the commenter's support for the proposed
payment update for FY 2019 and, as proposed, have used more recent data
to determine the market basket percentage for the final rule.
Comment: One commenter requested CMS provide access to the analyses
done by contractors to calculate the market basket update each year.
Response: The market basket update is derived using (1) the market
basket base year cost weights as finalized by CMS through rulemaking
and (2) the most up-to-date forecast of the price proxies used in the
market basket as forecasted by IGI. As stated previously, IGI is a
nationally recognized economic and financial forecasting firm, with
which we contract to forecast the components of the market baskets and
MFP. To determine the market basket update, for each cost category in
the market basket (for example, Wages and Salaries, Pharmaceuticals),
the level of each of these price forecasts are multiplied by the cost
weight for that cost category. The sum of these products (that is,
weights multiplied by proxied index levels) for all cost categories
yields the composite index level in the market basket in a given year.
The most recent forecast of each market basket is available on the CMS
website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/MarketBasketData.html.
More detailed forecasts are readily available by request; please
send an email to [email protected] to be added to the mailing list
for detailed market basket forecasts.
Comment: Several commenters recommended that CMS carefully monitor
the impact productivity adjustments have on the rehabilitation hospital
sector, provide feedback to Congress as appropriate, and utilize any
authority the agency has to reduce the productivity adjustment. One
commenter stated their concern that IRFs will not have the ability to
generate additional productivity gains at a pace matching the
productivity of the economy at large on an ongoing, consistent basis as
currently contemplated by the PPACA. The commenter further noted the
difficulties in achieving productivity gains in the IRF setting due to
the labor intensive nature of the care and unchanging labor-intensive
standards such as the 3-hour therapy rule. One commenter specifically
requested that CMS provide feedback to Congress, which would include a
proposal to end the productivity adjustment effective with the end of
the mandated PPACA Market Basket reductions.
Response: We acknowledge the commenters' concerns regarding MFP
growth at the economy-wide level and its application to IRFs. As stated
above, section 1886(j)(3)(C)(ii)(I) of the Act requires the application
of a productivity adjustment to the IRF PPS market basket increase
factor.
We will continue to monitor the impact of the payment updates,
including the effects of the productivity adjustment, on IRF provider
margins as well as beneficiary access to care. We note that each year,
MedPAC makes an annual update recommendation to Congress based on a
variety of measures related to payment adequacy, including analysis
that showed freestanding IRF Medicare margins have been above 10
percent since 2011.
Comment: One commenter (MedPAC) noted that while they understand
that CMS is required to implement the statutory update for IRF payment
for FY 2019, the commenter continue to recommend that IRF payment rates
be reduced by 5 percent for FY 2019. The commenter noted that this
recommendation is based on a review of many factors--including
indicators of beneficiary access to rehabilitative services, the supply
of providers, and aggregate IRF Medicare margins, which have been above
10 percent since 2011. The commenter also noted their appreciation that
CMS cited their recommendation, even though the Secretary does not have
the authority to deviate from statutorily mandated updates.
Response: As discussed, in accordance with section 1886(j)(3)(C) of
the Act, the increase factor for FY 2019 must be set equal to the FY
2019 projected market basket increase factor, reduced by the
productivity adjustment, and further reduced by a 0.75 percent
statutorily required adjustment. Section 1886(j)(3)(C) of the Act does
not provide the Secretary with the authority to apply a different
update factor to IRF PPS payment rates for FY 2019.
Final Decision: After careful consideration of comments, we are
finalizing the FY 2019 IRF update of 1.35 percent.
C. Labor-Related Share for FY 2019
Section 1886(j)(6) of the Act specifies that the Secretary is to
adjust the proportion (as estimated by the Secretary from time to time)
of rehabilitation facilities' costs which are attributable to wages and
wage-related costs of the prospective payment rates computed under
section 1886(j)(3) of the Act for area differences in wage levels by a
factor (established by the Secretary) reflecting the relative hospital
wage level in the geographic area of the rehabilitation facility
compared to the national average wage level for such facilities. The
labor-related share is determined by identifying the national average
proportion of total costs that are related to, influenced by, or vary
with the local labor market. We continue to classify a cost category as
labor-related if the costs are labor-intensive and vary with the local
labor market.
Based on our definition of the labor-related share and the cost
categories in the 2012-based IRF market basket, we proposed to
calculate the labor-related share for FY 2019 as the sum of the FY 2019
relative importance of Wages and Salaries, Employee Benefits,
Professional Fees: Labor-Related, Administrative and Facilities Support
Services, Installation, Maintenance, and Repair Services, All Other:
Labor-related Services, and a portion of the Capital-Related cost
weight from the 2012-based IRF market basket. For more details
regarding the methodology for determining specific cost categories for
inclusion in the 2012-based IRF labor-related share, see the FY 2016
IRF final rule (80 FR 47066 through 47068).
Using this method and IGI's first quarter 2018 forecast for the
2012-based IRF market basket, the proposed IRF labor-related share for
FY 2019 was 70.6 percent. We also proposed that if more recent data
were subsequently available (for example, a more recent estimate of the
labor-related share), we would use such data to determine the FY 2019
IRF labor-related share in the final rule.
Incorporating the most recent estimate of the 2012-based IRF market
basket based on IGI's second quarter 2018 forecast with historical data
through the first quarter of 2018, the sum of the relative importance
for FY 2019 operating costs (Wages and Salaries, Employee Benefits,
Professional Fees: Labor-related, Administrative and Facilities Support
Services, Installation Maintenance & Repair Services, and All Other:
Labor-related Services) using the 2012-based IRF market basket is 66.7
percent. We proposed that the portion of Capital-Related Costs that are
influenced by the local labor market was estimated to be 46 percent.
Incorporating the most recent estimate of the FY 2019 relative
importance of Capital-Related costs from the 2012-
[[Page 38526]]
based IRF market basket based on IGI's second quarter 2018 forecast
with historical data through the first quarter of 2018, which is 8.2
percent, we take 46 percent of 8.2 percent to determine the labor-
related share of Capital for FY 2019. We proposed to then add this
amount (3.8 percent) to the sum of the relative importance for FY 2019
operating costs (66.7 percent) to determine the total labor-related
share for FY 2019 of 70.5 percent.
Table 4--IRF Labor-Related Share
------------------------------------------------------------------------
FY 2019 final FY 2018 final
labor-related labor related
share \1\ share \2\
------------------------------------------------------------------------
Wages and Salaries.................... 47.7 47.8
Employee Benefits..................... 11.1 11.2
Professional Fees: Labor-related...... 3.4 3.4
Administrative and Facilities Support 0.8 0.8
Services.............................
Installation, Maintenance, and Repair 1.9 1.9
Services.............................
All Other: Labor-related Services..... 1.8 1.8
---------------------------------
Subtotal.......................... 66.7 66.9
Labor-related portion of capital (46%) 3.8 3.8
---------------------------------
Total Labor-Related Share......... 70.5 70.7
------------------------------------------------------------------------
\1\ Based on the 2012-based IRF Market Basket, IGI's 2nd quarter 2018
forecast with historical data through the 1st quarter of 2018.
\2\ Federal Register (82 FR 36249).
Final Decision: As we did not receive any comments on the proposed
labor-related share for FY 2019, we are finalizing the FY 2019 labor-
related share of 70.5 percent.
D. Wage Adjustment for FY 2019
1. Background
Section 1886(j)(6) of the Act requires the Secretary to adjust the
proportion of rehabilitation facilities' costs attributable to wages
and wage-related costs (as estimated by the Secretary from time to
time) by a factor (established by the Secretary) reflecting the
relative hospital wage level in the geographic area of the
rehabilitation facility compared to the national average wage level for
those facilities. The Secretary is required to update the IRF PPS wage
index on the basis of information available to the Secretary on the
wages and wage-related costs to furnish rehabilitation services. Any
adjustment or updates made under section 1886(j)(6) of the Act for a FY
are made in a budget-neutral manner.
For FY 2019, we proposed to maintain the policies and methodologies
described in the FY 2018 IRF PPS final rule (82 FR 36238, 36249 through
36250) related to the labor market area definitions and the wage index
methodology for areas with wage data. Thus, we proposed to use the CBSA
labor market area definitions and the FY 2018 pre-reclassification and
pre-floor hospital wage index data. In accordance with section
1886(d)(3)(E) of the Act, the FY 2018 pre-reclassification and pre-
floor hospital wage index is based on data submitted for hospital cost
reporting periods beginning on or after October 1, 2013, and before
October 1, 2014 (that is, FY 2014 cost report data).
The labor market designations made by the OMB include some
geographic areas where there are no hospitals and, thus, no hospital
wage index data on which to base the calculation of the IRF PPS wage
index. We proposed to continue to use the same methodology discussed in
the FY 2008 IRF PPS final rule (72 FR 44299) to address those
geographic areas where there are no hospitals and, thus, no hospital
wage index data on which to base the calculation for the FY 2019 IRF
PPS wage index.
We received 9 public comments on the proposed wage index adjustment
and related policies for FY 2019, which are summarized below.
Comment: Commenters suggested that we should use the FY 2019 IPPS
pre-reclassified acute care hospital wage index in the calculation of
the FY 2019 IRF PPS wage index, as we do for the IPPS, the long-term
care hospital PPS, the skilled nursing facility PPS, and the home
health PPS, rather than using the FY 2018 IPPS pre-reclassified acute
care hospital wage index, as we do in the IRF PPS, the inpatient
psychiatric facility PPS, and the hospice PPS. Commenters indicated
that using the same wage index data for the IRF PPS that is used in
other post-acute and acute care settings would eliminate one difference
between Medicare payments for IRFs and Medicare payments for other
post-acute and acute care providers, thereby allowing IRFs to
demonstrate their cost-effectiveness relative to other post-acute care
service providers. By demonstrating their cost-effectiveness relative
to other post-acute care service providers, IRFs would have more of an
opportunity to participate successfully in alternative payment models
currently being tested by Medicare, which generally provide financial
incentives for cost effectiveness.
Response: Consistent with historical practice and to ensure the
stability and predictability of Medicare payments under the IRF PPS, we
proposed to update the IRF wage index for FY 2019 using the FY 2018
pre-reclassification and pre-floor acute care hospital wage index (that
is, using a one-year lag of the hospital wage index). The FY 2018 pre-
reclassification and pre-floor hospital wage index values are based on
data collected from the Medicare cost reports submitted by hospitals
for cost reporting periods beginning in FY 2014. We use FY 2014 cost
reporting period data to determine the applicable IRF PPS wage index
values because, at the point we use these data, the values are more
stable and do not tend to change. We do not believe that our continued
use of the one-year lag of the hospital wage index for the IRF PPS
hinders the ability of IRFs to demonstrate their cost effectiveness.
However, we will continue to analyze these issues for future policy
development.
Comment: One commenter requested that, until a new wage index
system is implemented, we should establish a smoothing variable to be
applied to the current IRF wage index to reduce the fluctuations IRFs
experience annually.
Response: As stated above, under section 1886(j)(6) of the Act, we
adjust IRF PPS rates to account for differences in area wage levels.
Any perceived volatility in the wage index is predicated upon
volatility in actual
[[Page 38527]]
wages in that area and reflects real differences in area wage levels.
As we believe that the application of a smoothing variable would make
the wage index values less reflective of the area wage levels, we do
not believe it would be appropriate to implement such a change to the
IRF wage index policy.
As we most recently discussed in the FY 2018 IRF PPS final rule (82
FR 36238, 36250), section 3137(b) of the PPACA required us to submit a
report to the Congress by December 31, 2011 that included a plan to
reform the hospital wage index system. This report describes the
concept of a Commuting Based Wage Index as a potential replacement to
the current Medicare wage index methodology. While this report
addresses the goals of broad based Medicare wage index reform, no
consensus has been achieved regarding how best to implement a
replacement system. This concern will be taken into consideration while
we continue to explore potential wage index reforms. The report that we
submitted is available online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Wage-Index-Reform.html.
Comment: One commenter requested that CMS implement a wage index
floor of 1.00 for IRFs located in frontier states.
Response: As we do not have an IRF-specific wage index, we are
unable to determine if a rural floor policy under the IRF PPS would be
appropriate. The rationale for our current wage index policies is fully
described in the FY 2006 IRF PPS final rule (70 FR 47880, 47926 through
47928).
Additionally, as most recently noted in the FY 2017 IRF PPS Final
rule (81 FR 52075) MedPAC's June 2007 report to the Congress, titled
``Report to Congress: Promoting Greater Efficiency in Medicare''
(available at http://www.medpac.gov/-/documents/-/reports), recommends
that Congress ``repeal the existing hospital wage index statute,
including reclassification and exceptions, and give the Secretary
authority to establish a new wage index systems.'' We continue to
believe it would not be appropriate, at this time, to adopt wage index
policies afforded to acute care hospitals into the IRF PPS, such as a
rural floor policy. Therefore, we will continue to use the CBSA labor
market area definitions and the pre-reclassification and pre-floor
hospital wage index data based on 2014 cost report data.
Final Decision: After careful consideration of the comments, we are
finalizing our proposal to use the CBSA labor market area definitions
and the FY 2018 pre-reclassification and pre-floor hospital wage index
data for areas with wage data. We are also finalizing our proposal to
continue to use the same methodology discussed in the FY 2008 IRF PPS
final rule (72 FR 44299) to address those geographic areas where there
are no hospitals and, thus, no hospital wage index data.
2. Core-Based Statistical Areas (CBSAs) for the Proposed FY 2019 IRF
Wage Index
The wage index used for the IRF PPS is calculated using the pre-
reclassification and pre-floor acute care hospital wage index data and
is assigned to the IRF on the basis of the labor market area in which
the IRF is geographically located. IRF labor market areas are
delineated based on the CBSAs established by the OMB. The current CBSA
delineations (which were implemented for the IRF PPS beginning with FY
2016) are based on revised OMB delineations issued on February 28,
2013, in OMB Bulletin No. 13-01. OMB Bulletin No. 13-01 established
revised delineations for Metropolitan Statistical Areas, Micropolitan
Statistical Areas, and Combined Statistical Areas in the United States
and Puerto Rico based on the 2010 Census, and provided guidance on the
use of the delineations of these statistical areas using standards
published on June 28, 2010, in the Federal Register (75 FR 37246
through 37252). We refer readers to the FY 2016 IRF PPS final rule (80
FR 47068 through 47076) for a full discussion of our implementation of
the OMB labor market area delineations beginning with the FY 2016 wage
index.
Generally, OMB issues major revisions to statistical areas every 10
years, based on the results of the decennial census. However, OMB
occasionally issues minor updates and revisions to statistical areas in
the years between the decennial censuses. On July 15, 2015, OMB issued
OMB Bulletin No. 15-01, which provides minor updates to and supersedes
OMB Bulletin No. 13-01 that was issued on February 28, 2013. The
attachment to OMB Bulletin No. 15-01 provides detailed information on
the update to statistical areas since February 28, 2013. The updates
provided in OMB Bulletin No. 15-01 are based on the application of the
2010 Standards for Delineating Metropolitan and Micropolitan
Statistical Areas to Census Bureau population estimates for July 1,
2012 and July 1, 2013. The complete list of statistical areas
incorporating these changes is provided in OMB Bulletin No. 15-01. In
the FY 2018 IRF PPS final rule (82 FR 36250 through 36251), we adopted
the updates set forth in OMB Bulletin No. 15-01 effective October 1,
2017, beginning with the FY 2018 wage index. For a complete discussion
of the adoption of the updates set forth in OMB Bulletin No. 15-01, we
refer readers to the FY 2018 IRF PPS final rule.
For FY 2019, we proposed to continue using the OMB delineations
that we adopted beginning with FY 2016 to calculate the area wage
indexes, with the updates set forth in OMB Bulletin No. 15-01 that we
adopted beginning with the FY 2018 wage index.
We invited public comment on our proposal to continue using the OMB
delineations that we adopted beginning with FY 2016 to calculate the
area wage indexes for FY 2019. We received one comment on the use of
these OMB delineations, which is summarized below.
Comment: One commenter requested that CMS extend the transition
period that was afforded to rural IRFs that transitioned to urban
status due to the adoption of updated OMB delineations that were
finalized in the FY 2016 IRF PPS final rule. This commenter requested
that CMS extend the transition period to at least 5 years or allow the
affected facilities to apply for reclassification back to rural status
for a 5-year period.
Response: We believe the 3-year transition was sufficient to
mitigate any adverse payment impacts for these IRFs while also ensuring
that payment rates for all IRF providers are set accurately and
appropriately. As the wage index is a relative measure of the value of
labor in prescribed labor market areas, we do not believe it is
appropriate to expand the transition wage index beyond than what was
finalized. We believe extending the transition would further delay the
use of what we believe are accurate wage index rates. As we did not
propose any such changes, this comment is out of scope of the proposed
rule.
Final Decision: After careful consideration of the comment we
received on the proposal to continue using the OMB delineations that we
adopted beginning with FY 2016 to calculate the area wage indexes for
FY 2019, we are finalizing this policy for FY 2019.
3. Codes for Constituent Counties in CBSAs
CBSAs are made up of one or more constituent counties. Each CBSA
and constituent county has its own unique identifying codes. There are
two different lists of codes associated with
[[Page 38528]]
counties: Social Security Administration (SSA) codes and Federal
Information Processing Standard (FIPS) codes. Historically, we have
used SSA and FIPS county codes to identify and crosswalk counties to
CBSA codes for purposes of the IRF wage index. We have learned that SSA
county codes are no longer being maintained and updated. However, the
FIPS codes continue to be maintained by the U.S. Census Bureau. The
Census Bureau's most current statistical area information is derived
from ongoing census data received since 2010; the most recent data are
from 2015. For purposes of cross-walking counties to CBSA codes, we
proposed to discontinue the use of SSA county codes and continue using
only the FIPS county codes. We proposed to use the FIPS county codes to
calculate area wage indexes in a manner that is generally consistent
with the CBSA-based methodologies finalized in the FY 2006 IRF final
rule (70 FR 47880) and the FY 2016 IRF final rule (80 FR 47036). The
use of the FIPS codes for cross-walking counties to CBSAs does not
result in any changes to the constituent counties of any CBSA. Thus,
there is no impact or change for any IRF due to the use of the FIPS
county codes. We believe that using the latest FIPS codes will allow us
to maintain a more accurate and up-to-date payment system that reflects
the reality of population shifts and labor market conditions.
As discussed in the FY 2018 Inpatient prospective payment system
(IPPS) and Long-Term Care Hospital (LTCH) PPS final rule (82 FR 38130),
this change was implemented under the IPPS beginning on October 1,
2017. Therefore, we proposed to implement this revision for the IRF PPS
beginning October 1, 2018, consistent with our historical practice of
modeling IRF PPS adoption of updates to labor market areas after IPPS
adoption of these changes.
We invited public comments on this proposal. However, we did not
receive any comments on the proposed revisions to the CBSA codes.
Final Decision: As we did not receive any comments on our proposal
to discontinue the use of SSA county codes and continue using only the
FIPS County codes for purposes of cross-walking counties to CBSA codes,
we are finalizing these changes for FY 2019.
4. Wage Adjustment
The wage index applicable to FY 2019 is available on the CMS
website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html. Table A is for urban
areas, and Table B is for rural areas.
To calculate the wage-adjusted facility payment for the payment
rates set forth in this final rule, we multiply the unadjusted federal
payment rate for IRFs by the FY 2019 labor-related share based on the
2012-based IRF market basket (70.5 percent) to determine the labor-
related portion of the standard payment amount. A full discussion of
the calculation of the labor-related share is located in section VI.C
of this final rule. We then multiply the labor-related portion by the
applicable IRF wage index from the tables in the addendum to this final
rule. These tables are available on the CMS website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html.
Adjustments or updates to the IRF wage index made under section
1886(j)(6) of the Act must be made in a budget-neutral manner. We
proposed to calculate a budget-neutral wage adjustment factor as
established in the FY 2004 IRF PPS final rule (68 FR 45689), codified
at Sec. 412.624(e)(1), as described in the steps below. We proposed to
use the listed steps to ensure that the FY 2019 IRF standard payment
conversion factor reflects the update to the wage indexes (based on the
FY 2014 hospital cost report data) and the labor-related share in a
budget-neutral manner:
Step 1. Determine the total amount of the estimated FY 2018 IRF PPS
payments, using the FY 2018 standard payment conversion factor and the
labor-related share and the wage indexes from FY 2018 (as published in
the FY 2018 IRF PPS final rule (82 FR 36238)).
Step 2. Calculate the total amount of estimated IRF PPS payments
using the FY 2019 standard payment conversion factor and the FY 2019
labor-related share and CBSA urban and rural wage indexes.
Step 3. Divide the amount calculated in step 1 by the amount
calculated in step 2. The resulting quotient is the FY 2019 budget-
neutral wage adjustment factor of 1.0000.
Step 4. Apply the FY 2019 budget-neutral wage adjustment factor
from step 3 to the FY 2018 IRF PPS standard payment conversion factor
after the application of the increase factor to determine the FY 2019
standard payment conversion factor.
We discuss the calculation of the standard payment conversion
factor for FY 2019 in section VI.E. of this final rule.
We invited public comments on this proposal. However, we did not
receive any comments on the proposed methodology for calculating the
budget-neutral wage index.
Final Decision: As we did not receive any comments on the proposed
methodology for calculating the budget-neutral wage index, we are
finalizing this policy for FY 2019.
E. Description of the IRF Standard Payment Conversion Factor and
Payment Rates for FY 2019
To calculate the standard payment conversion factor for FY 2019, as
illustrated in Table 5, we begin by applying the increase factor for FY
2019, as adjusted in accordance with sections 1886(j)(3)(C) and (D) of
the Act, to the standard payment conversion factor for FY 2018
($15,838). Applying the 1.35 percent increase factor for FY 2019 to the
standard payment conversion factor for FY 2018 of $15,838 yields a
standard payment amount of $16,052. Then, we apply the budget
neutrality factor for the FY 2019 wage index and labor-related share of
1.0000, which results in a standard payment amount of $16,052. We next
apply the budget neutrality factor for the revised CMG relative weights
of 0.9981, which results in the standard payment conversion factor of
$16,021 for FY 2019.
Table 5--Calculations To Determine the FY 2019 Standard Payment
Conversion Factor
------------------------------------------------------------------------
Explanation for adjustment Calculations
------------------------------------------------------------------------
Standard Payment Conversion Factor for FY 2018.......... $15,838
Market Basket Increase Factor for FY 2019 (2.9 percent), x 1.0135
reduced by 0.8 percentage point for the productivity
adjustment as required by section 1886(j)(3)(C)(ii)(I)
of the Act, and reduced by 0.75 percentage point in
accordance with sections 1886(j)(3)(C)(ii)(II) and
1886(j)(3)(D)(v) of the Act............................
Budget Neutrality Factor for the Wage Index and Labor- x 1.0000
Related Share..........................................
Budget Neutrality Factor for the Revisions to the CMG x 0.9981
Relative Weights.......................................
---------------
[[Page 38529]]
FY 2019 Standard Payment Conversion Factor.......... = $16,021
------------------------------------------------------------------------
We received 1 comment on the proposed FY 2019 standard payment
conversion factor.
Comment: The commenter noted that the FY 2019 standard payment
conversion factor does not include any additional payment to IRFs for
the time and resources needed to complete assessments for quality
reporting.
Response: Section 1886(j)(3) of the Act does not provide the
Secretary with the authority to adjust payments to reflect increases in
costs due to time and resources needed to complete assessments for
quality reporting. We will continue to monitor the impact of the FY
2019 payment updates and quality reporting requirements on IRF
providers.
Final Decision: After careful consideration of the comment we
received, we are finalizing the IRF standard payment conversion factor
of $16,021 for FY 2019.
After the application of the CMG relative weights described in
section IV of this final rule to the FY 2019 standard payment
conversion factor ($16,021), the resulting unadjusted IRF prospective
payment rates for FY 2019 are shown in Table 6.
Table 6--FY 2019 Payment Rates
----------------------------------------------------------------------------------------------------------------
Payment rate Payment rate Payment rate Payment rate
CMG tier 1 tier 2 tier 3 no comorbidity
----------------------------------------------------------------------------------------------------------------
0101............................................ $ 13,561.78 $ 11,799.47 $ 10,809.37 $ 10,335.15
0102............................................ 17,152.08 14,923.56 13,670.72 13,071.53
0103............................................ 19,851.62 17,272.24 15,822.34 15,128.63
0104............................................ 20,727.97 18,034.84 16,520.86 15,796.71
0105............................................ 23,824.83 20,727.97 18,988.09 18,156.60
0106............................................ 26,639.72 23,177.58 21,232.63 20,303.41
0107............................................ 29,883.97 26,000.48 23,818.42 22,775.45
0108............................................ 36,938.02 32,138.13 29,440.19 28,152.10
0109............................................ 33,415.00 29,073.31 26,633.31 25,466.98
0110............................................ 44,306.08 38,546.53 35,311.89 33,765.86
0201............................................ 13,193.29 10,618.72 9,487.64 8,854.81
0202............................................ 18,436.97 14,840.25 13,257.38 12,374.62
0203............................................ 20,383.52 16,405.50 14,657.61 13,680.33
0204............................................ 22,174.67 17,849.00 15,945.70 14,883.51
0205............................................ 26,162.29 21,056.40 18,813.46 17,559.02
0206............................................ 31,498.89 25,353.23 22,652.09 21,141.31
0207............................................ 39,833.01 32,061.23 28,643.95 26,734.24
0301............................................ 18,787.83 15,192.71 13,943.08 13,033.08
0302............................................ 22,985.33 18,589.17 17,059.16 15,945.70
0303............................................ 26,550.00 21,471.34 19,705.83 18,417.74
0304............................................ 33,969.33 27,471.21 25,212.25 23,565.29
0401............................................ 16,085.08 12,972.20 11,999.73 10,982.40
0402............................................ 23,828.03 19,218.79 17,776.90 16,269.33
0403............................................ 37,950.54 30,608.12 28,313.91 25,913.97
0404............................................ 64,687.99 52,173.99 48,263.26 44,171.50
0405............................................ 57,955.97 46,744.47 43,239.08 39,573.47
0501............................................ 14,692.86 11,447.00 10,581.87 9,724.75
0502............................................ 19,516.78 15,205.53 14,056.83 12,917.73
0503............................................ 24,281.43 18,919.20 17,488.52 16,070.67
0504............................................ 27,918.19 21,751.71 20,107.96 18,477.02
0505............................................ 31,973.11 24,912.66 23,028.59 21,162.14
0506............................................ 43,250.29 33,698.57 31,149.63 28,624.72
0601............................................ 17,200.15 13,204.51 12,214.41 11,131.39
0602............................................ 22,301.23 17,120.04 15,835.16 14,431.72
0603............................................ 27,434.36 21,061.21 19,479.93 17,754.47
0604............................................ 35,483.31 27,240.51 25,196.23 22,964.50
0701............................................ 16,469.59 13,436.81 12,733.49 11,488.66
0702............................................ 20,960.27 17,100.82 16,205.24 14,622.37
0703............................................ 24,992.76 20,391.53 19,324.53 17,435.65
0704............................................ 31,893.00 26,021.31 24,659.52 22,249.96
0801............................................ 13,443.22 10,959.97 9,908.99 9,218.48
0802............................................ 17,248.21 14,061.63 12,714.27 11,826.70
0803............................................ 22,626.46 18,446.58 16,677.86 15,514.74
0804............................................ 20,389.93 16,623.39 15,029.30 13,981.53
0805............................................ 24,302.25 19,813.17 17,913.08 16,663.44
0806............................................ 29,944.85 24,412.80 22,072.13 20,532.51
0901............................................ 16,474.39 12,933.75 11,985.31 11,044.88
0902............................................ 20,875.36 16,389.48 15,186.31 13,995.95
0903............................................ 26,053.35 20,455.61 18,954.45 17,467.70
0904............................................ 32,637.98 25,625.59 23,744.72 21,883.08
1001............................................ 17,528.58 14,835.45 13,178.87 12,150.33
[[Page 38530]]
1002............................................ 22,403.77 18,960.85 16,842.88 15,529.16
1003............................................ 32,437.72 27,453.59 24,387.17 22,483.87
1101............................................ 21,817.40 16,091.49 16,091.49 14,149.75
1102............................................ 30,773.14 22,696.95 22,696.95 19,958.96
1201............................................ 17,823.36 15,285.64 13,954.29 12,619.74
1202............................................ 22,576.79 19,361.38 17,674.37 15,985.75
1203............................................ 27,343.04 23,449.94 21,405.66 19,359.78
1301............................................ 17,586.25 15,256.80 14,247.48 13,364.72
1302............................................ 22,998.15 19,952.55 18,632.42 17,477.31
1303............................................ 27,775.61 24,097.19 22,503.10 21,107.67
1401............................................ 14,780.97 12,033.37 10,849.42 9,777.62
1402............................................ 19,832.40 16,147.57 14,556.68 13,119.60
1403............................................ 23,634.18 19,242.82 17,347.54 15,634.89
1404............................................ 29,768.62 24,238.17 21,851.04 19,693.01
1501............................................ 16,253.30 14,023.18 12,699.85 12,169.55
1502............................................ 20,779.24 17,929.10 16,235.68 15,557.99
1503............................................ 24,657.92 21,275.89 19,266.85 18,462.60
1504............................................ 31,072.73 26,811.14 24,279.83 23,265.70
1601............................................ 19,422.26 14,867.49 14,120.91 12,743.10
1602............................................ 24,609.86 18,837.49 17,893.85 16,147.57
1603............................................ 29,858.34 22,855.56 21,710.06 19,590.48
1701............................................ 20,546.93 15,578.82 14,583.92 13,130.81
1702............................................ 24,848.57 18,840.70 17,637.52 15,880.02
1703............................................ 28,993.20 21,984.02 20,580.58 18,528.29
1704............................................ 37,003.70 28,057.58 26,266.43 23,648.60
1801............................................ 18,079.70 16,121.93 13,624.26 12,725.48
1802............................................ 26,657.34 23,771.96 20,088.73 18,763.80
1803............................................ 41,886.90 37,352.96 31,566.18 29,483.45
1901............................................ 22,429.40 16,099.50 15,123.82 14,572.70
1902............................................ 39,493.37 28,347.56 26,630.11 25,660.84
1903............................................ 68,360.00 49,067.52 46,095.62 44,418.22
2001............................................ 15,529.16 12,350.59 11,471.04 10,413.65
2002............................................ 20,181.65 16,049.84 14,909.14 13,534.54
2003............................................ 24,806.92 19,728.26 18,324.82 16,636.21
2004............................................ 31,615.84 25,144.96 23,355.41 21,202.19
2101............................................ 30,560.06 24,821.34 23,972.22 21,096.45
5001............................................ .............. .............. .............. 2,561.76
5101............................................ .............. .............. .............. 12,078.23
5102............................................ .............. .............. .............. 26,423.44
5103............................................ .............. .............. .............. 12,962.59
5104............................................ .............. .............. .............. 33,876.40
----------------------------------------------------------------------------------------------------------------
F. Example of the Methodology for Adjusting the Prospective Payment
Rates
Table 7 illustrates the methodology for adjusting the federal
prospective payments (as described in section VI. of this final rule).
The following examples are based on two hypothetical Medicare
beneficiaries, both classified into CMG 0110 (without comorbidities).
The unadjusted prospective payment rate for CMG 0110 (without
comorbidities) appears in Table 6.
Example: One beneficiary is in Facility A, an IRF located in rural
Spencer County, Indiana, and another beneficiary is in Facility B, an
IRF located in urban Harrison County, Indiana. Facility A, a rural non-
teaching hospital has a Disproportionate Share Hospital (DSH)
percentage of 5 percent (which would result in a LIP adjustment of
1.0156), a wage index of 0.8088, and a rural adjustment of 14.9
percent. Facility B, an urban teaching hospital, has a DSH percentage
of 15 percent (which would result in a LIP adjustment of 1.0454
percent), a wage index of 0.8689, and a teaching status adjustment of
0.0784.
To calculate each IRF's labor and non-labor portion of the
prospective payment, we begin by taking the unadjusted prospective
payment rate for CMG 0110 (without comorbidities) from Table 6. Then,
we multiply the labor-related share for FY 2019 (70.5 percent)
described in section VI.C. of this final rule by the unadjusted
prospective payment rate. To determine the non-labor portion of the
prospective payment rate, we subtract the labor portion of the federal
payment from the unadjusted prospective payment.
To compute the wage-adjusted prospective payment, we multiply the
labor portion of the federal payment by the appropriate wage index
located in Tables A and B. These tables are available on the CMS
website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html. The resulting figure is
the wage-adjusted labor amount. Next, we compute the wage-adjusted
federal payment by adding the wage-adjusted labor amount to the non-
labor portion of the federal payment.
Adjusting the wage-adjusted federal payment by the facility-level
adjustments involves several steps. First, we take the wage-adjusted
prospective payment and multiply it by the appropriate rural and LIP
adjustments (if applicable). Second, to determine the appropriate
amount of additional payment for the teaching status adjustment (if
applicable), we multiply the teaching status adjustment (0.0784, in
this example) by the wage-adjusted and rural-adjusted amount (if
applicable). Finally, we add the
[[Page 38531]]
additional teaching status payments (if applicable) to the wage, rural,
and LIP-adjusted prospective payment rates. Table 7 illustrates the
components of the adjusted payment calculation.
Table 7--Example of Computing the FY 2019 IRF Prospective Payment
------------------------------------------------------------------------
Urban facility B
Steps Rural facility A (Harrison Co.,
(Spencer Co., IN) IN)
------------------------------------------------------------------------
1. Unadjusted Payment............. $33,765.86 $33,765.86
2. Labor Share.................... x 0.705 x 0.705
3. Labor Portion of Payment....... = 23,804.93 = 23,804.93
4. CBSA-Based Wage Index (shown in x 0.8088 x 0.8689
the Addendum, Tables A and B)....
5. Wage-Adjusted Amount........... = 19,253.43 = 20,684.10
6. Non-Labor Amount............... + 9,960.93 + 9,960.93
7. Wage-Adjusted Payment.......... = 29,214.36 = 30,645.03
8. Rural Adjustment............... x 1.149 x1.000
9. Wage- and Rural-Adjusted = 33,567.30 = 30,645.03
Payment..........................
10. LIP Adjustment................ x 1.0156 x 1.0454
11. Wage-, Rural- and LIP-Adjusted = 34,090.95 = 32,036.32
Payment..........................
12. Wage- and Rural-Adjusted 33,567.30 30,645.03
Payment..........................
13. Teaching Status Adjustment.... x 0 x 0.0784
14. Teaching Status Adjustment = 0.00 = 2,402.57
Amount...........................
15. Wage-, Rural-, and LIP- + 34,090.95 + 32,036.32
Adjusted Payment.................
16. Total Adjusted Payment........ = 34,090.95 = 34,438.89
------------------------------------------------------------------------
Thus, the adjusted payment for Facility A would be $34,090.95, and
the adjusted payment for Facility B would be $34,438.89.
VII. Update to Payments for High-Cost Outliers Under the IRF PPS for FY
2019
A. Update to the Outlier Threshold Amount for FY 2019
Section 1886(j)(4) of the Act provides the Secretary with the
authority to make payments in addition to the basic IRF prospective
payments for cases incurring extraordinarily high costs. A case
qualifies for an outlier payment if the estimated cost of the case
exceeds the adjusted outlier threshold. We calculate the adjusted
outlier threshold by adding the IRF PPS payment for the case (that is,
the CMG payment adjusted by all of the relevant facility-level
adjustments) and the adjusted threshold amount (also adjusted by all of
the relevant facility-level adjustments). Then, we calculate the
estimated cost of a case by multiplying the IRF's overall CCR by the
Medicare allowable covered charge. If the estimated cost of the case is
higher than the adjusted outlier threshold, we make an outlier payment
for the case equal to 80 percent of the difference between the
estimated cost of the case and the outlier threshold.
In the FY 2002 IRF PPS final rule (66 FR 41362 through 41363), we
discussed our rationale for setting the outlier threshold amount for
the IRF PPS so that estimated outlier payments would equal 3 percent of
total estimated payments. For the 2002 IRF PPS final rule, we analyzed
various outlier policies using 3, 4, and 5 percent of the total
estimated payments, and we concluded that an outlier policy set at 3
percent of total estimated payments would optimize the extent to which
we could reduce the financial risk to IRFs of caring for high-cost
patients, while still providing for adequate payments for all other
(non-high cost outlier) cases.
Subsequently, we updated the IRF outlier threshold amount in the
FYs 2006 through 2018 IRF PPS final rules and the FY 2011 and FY 2013
notices (70 FR 47880, 71 FR 48354, 72 FR 44284, 73 FR 46370, 74 FR
39762, 75 FR 42836, 76 FR 47836, 76 FR 59256, 77 FR 44618, 78 FR 47860,
79 FR 45872, 80 FR 47036, 81 FR 52056, and 82 FR 36238, respectively)
to maintain estimated outlier payments at 3 percent of total estimated
payments. We also stated in the FY 2009 final rule (73 FR 46370 at
46385) that we would continue to analyze the estimated outlier payments
for subsequent years and adjust the outlier threshold amount as
appropriate to maintain the 3 percent target.
To update the IRF outlier threshold amount for FY 2019, we proposed
to use FY 2017 claims data and the same methodology that we used to set
the initial outlier threshold amount in the FY 2002 IRF PPS final rule
(66 FR 41316 and 41362 through 41363), which is also the same
methodology that we used to update the outlier threshold amounts for
FYs 2006 through 2018. The outlier threshold is calculated by
simulating aggregate payments and using an iterative process to
determine a threshold that results in outlier payments being equal to 3
percent of total payments under the simulation. To determine the
outlier threshold for FY 2019, we estimate the amount of FY 2019 IRF
PPS aggregate and outlier payments using the most recent claims
available (FY 2017) and the FY 2019 standard payment conversion factor,
labor-related share, and wage indexes, incorporating any applicable
budget-neutrality adjustment factors. The outlier threshold is adjusted
either up or down in this simulation until the estimated outlier
payments equal 3 percent of the estimated aggregate payments. Based on
an analysis of the preliminary data used for the proposed rule, we
estimated that IRF outlier payments as a percentage of total estimated
payments would be approximately 3.4 percent in FY 2018. Therefore, we
proposed to update the outlier threshold amount from $8,679 for FY 2018
to $10,509 for FY 2019 to maintain estimated outlier payments at
approximately 3 percent of total estimated aggregate IRF payments for
FY 2019.
We note that, as we typically do, we updated our data between the
FY 2019 IRF PPS proposed and final rules to ensure that we use the most
recent available data in calculating IRF PPS payments. This updated
data includes a more complete set of claims for FY 2017. Based on our
analysis using this updated data, we now estimate that IRF outlier
payments as a percentage of total estimated payments are approximately
3.1 percent in FY 2018. Therefore, we will update the outlier threshold
amount from $8,679 for FY 2018 to $9,402 for FY 2019 to account for the
increases in IRF PPS payments and estimated costs and to maintain
estimated outlier payments at
[[Page 38532]]
approximately 3 percent of total estimated aggregate IRF payments for
FY 2019.
We received 5 comments on the proposed update to the FY 2019
outlier threshold amount to maintain estimated outlier payments at
approximately 3 percent of total estimated IRF payments, which are
summarized below.
Comment: Some commenters were supportive of maintaining estimated
payments for outlier payments at approximately 3 percent and requested
that CMS update the outlier threshold amount in the final rule using
the latest available data. One commenter reiterated their
recommendation to expand the outlier pool from 3 to 5 percent to
redistribute payments within the IRF PPS and to reduce the impact of
misalignments between IRF payments and costs. Specifically, the
commenter suggested that expanding the outlier pool would help to
ameliorate the financial burden on IRFs that have a relatively high
share of costly cases. However, this same commenter noted that such an
expansion in the outlier pool could inappropriately reward some
facilities for inefficiencies. Another commenter suggested that CMS
should lower the outlier pool below 3 percent.
Response: We agree that we should use the most recent data
available to calculate the outlier threshold. Therefore, as previously
stated, we updated the data used to calculate the outlier threshold
between the FY 2019 IRF PPS proposed and final rule.
We refer readers to the 2002 IRF PPS final rule (66 FR 41316, 41362
through 41363), for a discussion of the rationale for setting the
outlier threshold amount for the IRF PPS so that estimated outlier
payments would equal 3 percent of total estimated payments. For the
2002 IRF PPS final rule, we analyzed various outlier policies using 3,
4, and 5 percent of the total estimated payments, and we concluded that
an outlier policy set at 3 percent of total estimated payments would
optimize the extent to which we could reduce the financial risk to IRFs
of caring for high-cost patients, while still providing for adequate
payments for all other (non-high cost outlier) cases. We continue to
believe that the outlier policy of 3 percent of total estimated
aggregate payments accomplishes this objective. Increasing the outlier
pool would leave less money available to cover the costs of non-outlier
cases, due to the fact that we would implement such a change in a
budget-neutral manner. We believe that our current outlier policy, to
set outlier payments at 3 percent of total estimated aggregate
payments, is consistent with the statute and the goals of the IRF PPS.
Comment: Several commenters stated that CMS should ensure that the
full 3 percent outlier pool is paid out to providers, as the commenters
indicated that CMS has paid out less than the estimated 3 percent in
the past. Some commenters suggested implementing a forecast error
correction if the full amount of the outlier pool is not paid out.
Response: We appreciate the commenters' analyses and suggestions
regarding the outlier threshold calculations. Our analysis of recent
data shows that IRF outlier payments as a percentage of total estimated
aggregate payments are approximately 3.1 percent in FYs 2017 and 2018,
thus indicating that we paid out more than 3 percent, not less, in the
2 most recent fiscal years. Thus, we have not found that our outlier
threshold calculations show any tendency to underpay on outlier
payments.
However, we will continue to monitor our IRF outlier policies to
ensure that they continue to compensate IRFs appropriately for treating
unusually high-cost patients and do not limit access to care for
patients who are likely to require unusually high-cost care. As we most
recently noted in the FY 2018 IRF PPS final rule (82 FR 36255), we do
not make adjustments to IRF PPS payment rates for the sole purpose of
accounting for differences between projected and actual outlier
payments. We use the best available data at the time to establish an
outlier threshold for IRF PPS payments prior to the beginning of each
fiscal year to help ensure that estimated outlier payments for that
fiscal year will equal 3 percent of total estimated IRF PPS payments.
We analyze expenditures annually, and if there is a difference from our
projection, that information is used to make a prospective adjustment
to lower or raise the outlier threshold for the upcoming fiscal year.
We believe a retrospective adjustment would not be appropriate to
recoup or make excess payments to hospitals.
If outlier payments for a given year turn out to be greater than
projected, we do not recoup money from hospitals; if outlier payments
for a given year are lower than projected, we do not make an adjustment
to account for the difference. Payments for a given discharge in a
given fiscal year are generally intended to reflect or address the
prospective average costs of that discharge in that year; that goal
would be undermined if we adjusted IRF PPS payments to account for
``underpayments'' or ``overpayments'' in IRF outliers in previous
years.
Comment: Several commenters suggested that we consider implementing
a cap on the amount of outlier payments an individual IRF can receive
under the IRF PPS to ensure that outliers are fairly distributed.
Response: As we did not propose to implement a cap on the amount of
outlier payments an individual IRF can receive under the IRF PPS, these
comments are outside the scope of this rule. However, we note that any
future consideration given to imposing a limit on outlier payments
would have to carefully analyze and take into consideration the effect
on access to IRF care for certain high-cost populations.
Comment: One commenter expressed concern that the proposal to
increase the outlier threshold amount from $8,679 to $10,509 was too
large an increase and suggested that we increase the threshold by no
more than 5 or 10 percent.
Response: We note that, as is our standard practice, we have used
updated data to calculate the FY 2019 IRF outlier threshold for this
final rule, which results in us finalizing a lower outlier threshold
amount ($9,402) than we proposed ($10,509) for FY 2019. We believe that
this decrease between the proposed and final outlier threshold amount
for FY 2019 should at least partially address the commenter's stated
concerns. We note, however, that our methodology is designed to
maintain estimated outlier payments at 3 percent of total estimated
payments, and we do not adjust the outlier threshold amount beyond what
is required to meet the target percentage.
Final Decision: Having carefully considered the public comments
received and also taking into account the most recent available data,
we are finalizing the outlier threshold amount of $9,402 to maintain
estimated outlier payments at approximately 3 percent of total
estimated aggregate IRF payments for FY 2019.
B. Update to the IRF Cost-to-Charge Ratio Ceiling and Urban/Rural
Averages for FY 2019
Cost-to-charge ratios are used to adjust charges from Medicare
claims to costs and are computed annually from facility-specific data
obtained from Medicare cost reports. IRF specific cost-to-charge ratios
are used in the development of the CMG relative weights and the
calculation of outlier payments under the IRF prospective payment
system. In accordance with the methodology stated in the FY 2004 IRF
PPS final rule (68 FR 45674, 45692 through 45694), we proposed to apply
a ceiling to IRFs' CCRs. Using the methodology described in that final
[[Page 38533]]
rule, we proposed to update the national urban and rural CCRs for IRFs,
as well as the national CCR ceiling for FY 2019, based on analysis of
the most recent data that is available. We apply the national urban and
rural CCRs in the following situations:
New IRFs that have not yet submitted their first Medicare
cost report.
IRFs whose overall CCR is in excess of the national CCR
ceiling for FY 2019, as discussed below in this section.
Other IRFs for which accurate data to calculate an overall
CCR are not available.
Specifically, for FY 2019, we proposed to estimate a national
average CCR of 0.518 for rural IRFs, which we calculated by taking an
average of the CCRs for all rural IRFs using their most recently
submitted cost report data. Similarly, we proposed to estimate a
national average CCR of 0.414 for urban IRFs, which we calculated by
taking an average of the CCRs for all urban IRFs using their most
recently submitted cost report data. We apply weights to both of these
averages using the IRFs' estimated costs, meaning that the CCRs of IRFs
with higher total costs factor more heavily into the averages than the
CCRs of IRFs with lower total costs. For this final rule, we have used
the most recent available cost report data (FY 2016). This includes all
IRFs whose cost reporting periods begin on or after October 1, 2015,
and before October 1, 2016. If, for any IRF, the FY 2016 cost report
was missing or had an ``as submitted'' status, we used data from a
previous fiscal year's (that is, FY 2004 through FY 2015) settled cost
report for that IRF. We do not use cost report data from before FY 2004
for any IRF because changes in IRF utilization since FY 2004 resulting
from the 60 percent rule and IRF medical review activities suggest that
these older data do not adequately reflect the current cost of care.
Using updated FY 2016 cost report data for this final rule, we estimate
a national average CCR of 0.515 for rural IRFs, and a national average
CCR of 0.412 for urban IRFs.
In accordance with past practice, we proposed to set the national
CCR ceiling at 3 standard deviations above the mean CCR. Using this
method, we proposed a national CCR ceiling of 1.31 for FY 2019. This
means that, if an individual IRF's CCR were to exceed this ceiling of
1.31 for FY 2019, we would replace the IRF's CCR with the appropriate
proposed national average CCR (either rural or urban, depending on the
geographic location of the IRF). We calculated the proposed national
CCR ceiling by:
Step 1. Taking the national average CCR (weighted by each IRF's
total costs, as previously discussed) of all IRFs for which we have
sufficient cost report data (both rural and urban IRFs combined).
Step 2. Estimating the standard deviation of the national average
CCR computed in step 1.
Step 3. Multiplying the standard deviation of the national average
CCR computed in step 2 by a factor of 3 to compute a statistically
significant reliable ceiling.
Step 4. Adding the result from step 3 to the national average CCR
of all IRFs for which we have sufficient cost report data, from step 1.
Using the updated FY 2016 cost report data for this final rule, we
estimate a national average CCR ceiling of 1.32, using the same
methodology. We did not receive any comments on the proposed update to
the IRF CCR ceiling and the urban/rural averages for FY 2019.
Final Decision: As we did not receive any comments on the proposed
update to the IRF CCR ceiling and the urban/rural averages for FY 2019,
we are finalizing the national average urban CCR at 0.412, the national
average rural CCR at 0.515, and the national average CCR ceiling at
1.32 for FY 2019.
VIII. Removal of the FIMTM Instrument and Associated Function Modifiers
From the IRF-PAI Beginning With FY 2020 and Refinements to the Case-Mix
Classification System Beginning With FY 2020
A. Removal of the FIMTM Instrument and Associated Function Modifiers
From the IRF-PAI Beginning With FY 2020
Under section 1886(j)(2)(D) of the Act, the Secretary is authorized
to require rehabilitation facilities that provide inpatient hospital
services to submit such data as the Secretary deems necessary to
establish and administer the IRF PPS. In the FY 2002 IRF PPS final rule
(66 FR 41324 through 41328), we finalized the use of the IRF-PAI,
through which IRFs are now required to collect and electronically
submit patient data for all Medicare Part A FFS and Medicare Part C
(Medicare Advantage) patients. Data collected in the IRF-PAI is used to
classify patients into distinct payment groups based on clinical
characteristics and expected resource needs as well as to monitor the
quality of care furnished in IRFs.
The IRF-PAI currently in use under the IRF PPS (IRF-PAI version
2.0) was originally developed based on a modified version of the
Uniform Data System for medical rehabilitation (UDSmr) patient
assessment instrument, commonly referred to as the FIMTM.
Item 39 of the IRF-PAI version 2.0 contains 18 of the FIMTM
data elements and the FIMTM measurement scale that are used
to score both motor and cognitive functioning at admission and
discharge. The FIMTM data elements and measurement scale are
collectively referred to as the FIMTM instrument.
Additionally, items 29 through 38 of the IRF-PAI version 2.0 contain
Function Modifiers associated with the FIMTM instrument. The
FIMTM instrument and associated Function Modifiers are
currently used to assign a patient into a CMG for payment purposes
under the IRF PPS based on the patient's ability to perform specific
activities of daily living and, in some cases, the patient's cognitive
ability.
In the FY 2012 IRF PPS final rule (76 FR 47873 through 47883), we
established the IRF QRP in accordance with section 1886(j)(7) of the
Act and finalized revisions to the IRF-PAI to begin collecting data
items under the IRF QRP. Under the IRF QRP, the following data items
are collected in the Quality Indicators section of the IRF-PAI:
GG0130A1 Eating.
GG0130B1 Oral hygiene.
GG0130C1 Toileting hygiene.
GG0130E1 Shower/bathe self.
GG0130F1 Upper-body dressing.
GG0130G1 Lower-body dressing.
GG0130H1 Putting on/taking off footwear.
GG0170A1 Roll left and right.
GG0170B1 Sit to lying.
GG0170C1 Lying to sitting on side of bed.
GG0170D1 Sit to stand.
GG0170E1 Chair/bed-to-chair transfer.
GG0170F1 Toilet transfer.
GG0170I1 Walk 10 feet.
GG0170J1 Walk 50 feet with two turns.
GG0170K1 Walk 150 feet.
GG0170M1 One step curb.
H0350 Bladder continence.
H0400 Bowel continence.
BB0700 Expression of ideas and wants.
BB0800 Understanding verbal content.
C0500 Brief Interview for Mental Status (BIMS) summary
score.
Because these data items collect data that are similar in nature
to, and overlap with, data collected through the FIMTM
instrument and associated Function Modifiers, we proposed to remove the
FIMTM instrument and associated Function Modifiers from the
IRF-PAI beginning with FY 2020 to reduce administrative burden on IRFs.
[[Page 38534]]
Currently, data elements in the FIMTM instrument and
associated Function Modifiers capture data on eating, grooming,
bathing, dressing upper body, dressing lower body, toileting, bladder
management, bowel management, transfer to bed/chair/wheelchair,
transfer to toilet, transfer to tub/shower, walking or wheelchair use,
stair climbing, comprehension, expression, social interaction, problem
solving, and memory. The Function Modifiers are used to assist in the
scoring of the related FIMTM instrument data elements and
provide additional information as to how the FIMTM
instrument data element score has been determined. For example, item 29
(Bladder Level of Assistance) and item 30 (Bladder Frequency of
Accidents) are used to determine the score for the item 39G, the
Bladder data element contained in the FIMTM instrument.
Data items in the Quality Indicators section of the IRF-PAI capture
data on functional status, cognitive function, and changes in function
and cognitive function among other elements used for quality reporting.
For example, the data items in the Quality Indicators section of the
IRF-PAI capture data on eating, oral hygiene, toileting hygiene,
shower/bathing, dressing upper body, dressing lower body, bowel
continence, bladder continence, chair/bed-to-chair transfer, toilet
transfer, walking, stair climbing, expression of ideas and wants,
understanding verbal and non-verbal content, temporal orientation, and
memory/recall ability. As the data elements in the FIMTM
instrument (item 39 of the IRF-PAI) and associated Function Modifiers
(items 29 through 38 of the IRF-PAI) overlap, directly or indirectly,
with data items in the Quality Indicators section of the IRF-PAI, and
as we can now use data items in the Quality Indicators section of the
IRF-PAI to assign patients to CMGs for payment under the IRF PPS, we
believe that the collection of the FIMTM instrument and
associated Function Modifiers is no longer necessary. Accordingly, we
believe that continuing to collect the FIMTM instrument and
associated Function Modifiers places undue burden on IRFs.
Additionally, the removal of the FIMTM instrument and
associated Function Modifiers from the IRF-PAI would support the
broader goal to standardize data collection across PAC settings as
several of the data items we proposed to incorporate into the IRF case-
mix system in place of the FIMTM instrument and associated
Function Modifiers are similar to data elements that are also collected
on Skilled Nursing Facility (SNF) and LTCH assessment instruments. In
support of our goal to reduce administrative burden on providers, we
proposed to remove the FIMTM instrument (item 39) and
associated Function Modifiers (items 29 through 38) from the IRF-PAI
beginning with FY 2020, that is, for all IRF discharges beginning on or
after October 1, 2019. This decrease in burden will be accounted for in
the information collection under OMB control number (0938-0842).
We invited public comment on our proposal to remove the
FIMTM instrument and associated Function Modifiers from the
IRF-PAI beginning with FY 2020, that is, for all IRF discharges
beginning on or after October 1, 2019. We summarize and respond to the
comments received on this proposal and discuss our final decision on
this proposal in section VIII.B.4 of this final rule.
In section VIII.B of this final rule, we discuss the proposed CMG
case-mix classification revisions that are necessary to replace our use
of the FIMTM items in assigning CMGs with use of data items
located in the Quality Indicators section of the IRF-PAI.
B. Refinements to the Case-Mix Classification System Beginning With FY
2020
1. IRF Classification System Overview
Section 1886(j)(2) of the Act requires the Secretary to establish
case-mix groups for payment under the IRF PPS. Under section
1886(j)(2)(B) of the Act, the Secretary must assign each case-mix group
a weighting factor that reflects the relative facility resources used
for patients classified within the group as compared to patients
classified within other groups. Additionally, section 1886(j)(2)(C)(i)
of the Act requires the Secretary from time to time to adjust the
classifications and weighting factors as appropriate to reflect changes
in treatment patterns, technology, case-mix, number of payment units
for which payment is made under title XVIII of the Act, and other
factors which may affect the relative use of resources. Such
adjustments must be made in a manner so that changes in aggregate
payments under the classification system are a result of real changes
and are not a result of changes in coding that are unrelated to real
changes in case mix.
In the FY 2002 IRF PPS final rule (66 FR 41316), we established a
case-mix classification system for IRFs under the IRF PPS. Under the
case-mix classification system, a patient's principal diagnosis or
impairment is used to classify the patient into a RIC. The patient is
then placed into a CMG within the RIC, based on the patient's
functional status (motor and cognitive scores) and sometimes age. Other
special circumstances, such as the occurrence of very short stays, or
cases where the patient expired, are also considered in determining the
appropriate CMG. CMGs are further divided into tiers based on the
presence of certain comorbidities. These tiers reflect the differential
cost of care compared with the average beneficiary in a CMG. We refer
readers to the FY 2002 final rule (66 FR 41316) and the FY 2006 IRF
final rule (70 FR 47886) for a detailed discussion of the development
of, and refinements to, the IRF case-mix classification system.
As discussed in section VIII.A of this final rule, we proposed to
remove the FIMTM instrument and associated Function
Modifiers from the IRF-PAI beginning with FY 2020, that is, for all IRF
discharges beginning on or after October 1, 2019. This would
necessitate the incorporation of the data items collected on admission
and located in the Quality Indicators section of the IRF-PAI version
2.0 into the CMG classification system, as the FIMTM data
would no longer be available to assign patients to CMGs for purposes of
payment under the IRF PPS. In accordance with section 1886(j)(2)(C)(i)
of the Act and as specified in Sec. 412.620(c) we proposed to replace
our use of the FIMTM items in assigning CMGs with use of
data items located in the Quality Indicators section of the IRF-PAI. In
addition, to ensure that IRF payments are accurately calculated using
the data items located in the Quality Indicators section of the IRF-
PAI, we also proposed to update the functional status scores used in
the case-mix system and to revise the CMGs and update the relative
weights and average length of stay values associated with the revised
CMGs. We proposed to implement these revisions to the case-mix
classification system in a budget neutral manner.
We proposed to make these changes effective beginning with FY 2020,
that is, for discharges occurring on or after October 1, 2019, as they
require extensive systems changes. That is, we proposed to implement
these changes with a one-year delayed effective date to allow adequate
time for providers and vendors to make the necessary systems changes.
These proposed changes are discussed in detail below. We did not
propose any changes to the methodology used to update the CMGs,
relative weights and average length of stay values for FY 2019, that
is, for discharges occurring on or after October
[[Page 38535]]
1, 2018, and on or before September 30, 2019. For information on the
updates to the CMG relative weights and average length of stay values
for FY 2019, please refer to section IV of this final rule.
2. Changes to the Functional Status Scores Beginning With FY 2020
As discussed in the FY 2006 IRF final rule (70 FR 47886), under the
CMG case-mix classification system, a patient's principal diagnosis or
impairment is used to classify the patient into a RIC. After using the
RIC to define the first division among the inpatient rehabilitation
groups, a patient's motor and cognitive scores and age are used to
partition the cases further. To classify a patient into a CMG, IRFs use
the admission assessment data from the IRF-PAI to score a patient's
functional status. Currently, the functional status scores consist of
what are termed ``motor'' items and ``cognitive'' items. In addition to
the functional status scores, the patient's age may also influence the
patient's CMG classification. The motor items are generally indications
of the patient's physical functioning level. The cognitive items are
generally indications of the patient's mental functioning level, and
are related to the patient's ability to process and respond to
empirical factual information, use judgment, and accurately perceive
what is happening. Under the current case-mix system, the motor and
cognitive scores are derived from a combination of data elements in the
FIMTM instrument (item 39 of the IRF-PAI). Eating, grooming,
bathing, dressing upper body, dressing lower body, toileting, bladder
management, bowel management, transfer to bed/chair/wheelchair,
transfer to toilet, walking or wheelchair use, and stair climbing are
the data elements collected through the FIMTM instrument
that are currently used to compute a patient's weighted motor score.
Comprehension, expression, social interaction, problem solving, and
memory are the data elements collected through the FIMTM
instrument that are used to compute a patient's cognitive score. Each
data element is recorded on the IRF-PAI and scored on a scale of 1 to
7, with a 7 indicating complete independence in this area of
functioning, and a one indicating that a patient is very impaired in
this area of functioning. Additionally, a value of zero is used to
indicate that an activity did not occur. The scores for each data
element above are then used to determine the patient's weighted motor
score and cognitive score, which may be used to group a patient into a
CMG for payment purposes under the IRF PPS.
As discussed in section VIII.A of this final rule, we proposed to
remove the FIMTM instrument and associated Function
Modifiers from the IRF-PAI beginning with FY 2020. As the data in the
FIMTM instrument section will no longer be available to
determine the motor and cognitive scores used to assign patients to
CMGs, we proposed to use data items collected on admission and located
in the Quality Indicators section of the IRF-PAI to derive the
functional status scores used to assign patients to a CMG for payment
purposes under the IRF PPS. The Quality Indicators section of the IRF-
PAI includes data items that are similar to the data elements located
in the FIMTM instrument, in addition to new data elements
that capture additional functional status information.
In the summer of 2013, we contracted with Research Triangle
Institute, International (RTI) to explore use of the data items
collected in the Quality Indicators section of the IRF-PAI in setting
IRF PPS payments. Some of the data items collected in the Quality
Indicators section of the IRF-PAI were originally developed and tested
as part of the Post-Acute Care Payment Reform Demonstration (PAC-PRD)
version of the Continuity Assessment Record and Evaluation (CARE) Item
Set. The CARE item set was developed in response to a mandate in
section 5008 of the Deficit Reduction Act of 2005 (Pub. L. 109-171,
enacted on February 8, 2006) (DRA) to develop a uniform patient
assessment instrument to assess patients across all types of acute and
PAC providers.
In the first stage of this analysis, RTI hosted a Technical Expert
Panel (TEP) on September 18, 2014, which brought together researchers,
clinicians, and representatives from provider associations to discuss
exploratory research on the potential to incorporate the CARE data
items in the current case-mix system utilized in the IRF PPS. We
received helpful feedback on the exploratory research including
clinicians' views of the importance and significance of various
findings, input on the methodology used to incorporate the CARE items,
and potential limitations of the analysis. RTI's analysis of the
original CARE data set, along with guidance from the TEP, suggested the
need to derive different functional status measures from the data
collected in the Quality Indicators section of the IRF-PAI. The data
items from the Quality Indicators section of the IRF-PAI contain
slightly different information and utilize a different rating system
than the items collected on the FIMTM instrument. Thus, we
proposed to modify the IRF case-mix classification system to calculate
IRF PPS payments correctly using the admission data items from the
Quality Indicators section of the IRF-PAI. RTI considered a broad range
of the data items in the Quality Indicators section of the IRF-PAI to
identify the best predictors of IRF costs. These analyses examined all
motor, cognitive, and additional items collected at admission to
predict costs. The regression analysis indicated that the components of
functional status that were found to best predict costs were the
patient's motor function, a memory function, a communication function
based on comprehension and expression, and age.
The motor items used to derive the additive motor score are eating,
oral hygiene, toileting hygiene, shower bathe/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). The item used to derive the memory score is
the BIMS summary score, which is based on the repetition of three
words, temporal orientation, and recall. The communication score is
derived from the hearing, speech, and vision items including expression
of ideas and wants and understanding verbal and non-verbal content. We
proposed to incorporate a motor score, a memory score, a communication
score, and age into the IRF case-mix classification system. Currently,
the IRF case-mix system uses a weighted motor score and an unweighted
cognitive score. We did not propose to apply a weighting methodology to
the motor score at this time. We proposed to derive the scores for each
respective group of the functional status items described above by
calculating the sum of the items that constitute each functional status
component. For a more detailed discussion of these analyses, please
refer to the technical report, ``Analyses to Inform the Potential Use
of Standardized Patient Assessment Data Elements in the Inpatient
Rehabilitation Facility Prospective Payment System,'' available at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Research.html.
As noted in the proposed rule, we believe that it is appropriate to
utilize the admission data items located in the Quality Indicators
section of the IRF-PAI, as described above, in place of the FIM\TM\
items to determine functional status, as the data items located in the
Quality Indicators section are now
[[Page 38536]]
available and collected by all IRF providers for purposes of the IRF
QRP. We believed the proposed motor score, a memory score, a
communication score, and age should compose the functional status
scores in the IRF case-mix classification system, as our analysis
determined these to be the best predictors of cost. The removal of the
FIM\TM\ instrument and the incorporation of certain items from the
Quality Indicators section of the IRF-PAI to assign patients to CMGs
support our efforts to reduce burden on providers. Additionally, the
removal of the FIM\TM\ instrument and the incorporation of certain
items from the Quality Indicators section of the IRF-PAI into the CMG
case-mix system support our broader goal of standardizing assessment
data collection across PAC settings.
We proposed to utilize certain data items located in the Quality
Indicators section of the IRF-PAI, as described above, to generate the
functional status scores that will be used to group patients into CMGs
for payment purposes under the IRF PPS beginning in FY 2020.
We invited public comments on the proposed use of certain data
items located in the Quality Indicators section of the IRF-PAI, as
described above, for payment purposes under the IRF PPS beginning with
FY 2020, that is, for all IRF discharges beginning on or after October
1, 2019. We summarize and respond to the comments received on this
proposal and discuss our final decision on this proposal in section
VIII.B.4 of this final rule.
3. Updates to the Score Reassignment Methodology Beginning With FY 2020
As previously noted, the data items located in the Quality
Indicators section of the IRF-PAI utilize a different rating system
than the FIM\TM\ instrument. There are several important differences to
note regarding the rating systems for the data items from the Quality
Indicators section of the IRF-PAI and the data contained in the FIM\TM\
instrument. First, the data items from the Quality Indicators section
of the IRF-PAI are assessed based on a patient's usual performance
during the assessment period in contrast to the FIM\TM\ items, which
are assessed based on the patient's lowest functional score during the
assessment period. The data items from the Quality Indicators section
of the IRF-PAI are generally assessed using a 6 level rating scale for
the self-care and mobility elements and a 4 level scale for the
cognitive elements. The FIM\TM\ data items use a 7 level scale.
Additionally, the FIM\TM\ scale includes a value of zero to indicate an
activity did not occur or was not observed. The data items from the
Quality Indicators section of the IRF-PAI utilize the following four
codes to indicate why an activity did not occur: the patient refused to
complete an activity (code 07), the patient did not perform this
activity (code 09), the activity was not attempted due to environmental
limitations (code 10), or the activity was not attempted due to a
medical condition or safety concern (code 88).
As the rating scale for the data items in the Quality Indicators
section of the IRF-PAI captures multiple reasons an activity did not
occur, we proposed to modify the methodology currently used to reassign
values indicating an activity did not occur or was not observed, when
they are recorded on an item used for payment, beginning with FY 2020.
Currently, when a code of 0 appears for one of the FIMTM
items on the IRF-PAI used to determine payment, the item is reassigned
another value to determine the appropriate payment for the patient. In
the FY 2002 IRF PPS final rule (66 FR 41316), we finalized a
methodology to assign a code of 1 (indicating the patient needed total
assistance) whenever the recorded code indicated that the activity did
not occur. Subsequently, in the FY 2006 IRF PPS final rule, we revised
this methodology to assign a value of 2 when the transfer to toilet
item was coded with a zero value. For more information on the rationale
behind this decision we refer readers to the 2006 IRF PPS final rule
(70 FR 47896 through 47902). As the data items from the Quality
Indicators section of the IRF-PAI now utilize 4 values to indicate an
activity did not occur and a dash to indicate ``no information'', we
proposed to modify the reassignment methodology to incorporate the new
codes. For the self-care and mobility items identified above, we
proposed to recode values of 07, 09, 10, 88, and the presence of a dash
(``-'') to 1, the most dependent level, except the toilet transfer
item, which is recoded to 2. These recodes are consistent with the
current reassignment methodology rules. We also proposed to change the
way we treat specific values for the bowel continence and bladder
continence items, as our analysis of these items and current coding
guidelines indicate these changes are necessary. The bladder continence
and bowel continence items utilize a different scale than the other
function items and may capture clinical information that is not
necessarily reflective of a patient's functional ability. For instance,
the bladder continence scale includes the options ``no urine output''
or ``not applicable'' for cases where a patient may have renal failure
or an indwelling catheter. A clinical review of these cases determined
that patients for whom these values are coded are similar in terms of
resource needs and costliness to patients for whom functional ability
is captured. Based on this review, we proposed to recode these values
to be able to score the functional status of a patient when these
values are coded on the IRF-PAI. For the bladder continence item, we
proposed to reassign a value of 1 (stress incontinence only) to 0
(always continent), a value of 5 (no urine output) to 0 (always
continent), and a value of 9 (not applicable) to 4 (always
incontinent). For the bowel continence item, we proposed to reassign a
value of 9 (not rated) to 2 (frequently incontinent). For both items,
we proposed to reassign a missing score to 0 (always continent). As
noted in the proposed rule, we believe these changes are necessary to
update the score reassignment methodology used to derive the functional
status scores to reflect use of the new data items from the Quality
Indicators section of the IRF-PAI and to accurately assign payments
based on a patients' expected costliness.
We invited public comments on the proposed updates to the score
reassignment methodology beginning with FY 2020, that is, for all IRF
discharges beginning on or after October 1, 2019. We summarize and
respond to the comments received on this proposal and discuss our final
decision on this proposal in section VIII.B.4 of this final rule.
4. Refinements to the CMGs Beginning With FY 2020
As previously noted, we proposed to modify the methodology used to
update the CMGs used to classify IRF patients for purposes of
establishing payment amounts, beginning with FY 2020. We proposed to
implement revisions to the CMGs in a budget-neutral manner. As
discussed in the FY 2006 IRF PPS final rule (70 FR 47886 through
47887), the current CMGs were derived through Classification and
Regression Trees (CART) analysis that incorporated a patient's
functional status (motor score and cognitive score) and age into the
construction of the CMGs. Under the IRF case-mix classification system,
a patient's principal diagnosis or impairment is used to classify the
patient into a RIC. Currently, there are 21 diagnosis-based RICs. The
RICs are then further subdivided into 92 CMGs.
[[Page 38537]]
Of the 92 CMGs, patients are assigned to 87 of the CMGs based on the
patient's primary reason for rehabilitation care, age and functional
status. There are also five special CMGs to account for very short
stays and for patients who expire in the IRF.
The CART method is useful in identifying statistical relationships
among data and, using these relationships, constructing a predictive
model for organizing and separating a large set of data into smaller,
similar groups. CART ensures that the proposed CMGs recognize that
patients with clinically distinct resource needs are appropriately
grouped in the case-mix classification system. CART is an iterative
process that creates initial groups of patients then searches for ways
to split the initial groups to further decrease the clinical and cost
variances within a group and increase the explanatory power of the
CMGs.
As noted previously, the data items from the Quality Indicators
section of the IRF-PAI contain slightly different information and
utilize a different rating system than the items collected on the
FIM\TM\ instrument. Thus, we proposed to update the IRF case-mix
classification system to ensure that IRF PPS payments reflect as
closely as possible the costs of care when we convert to using the
admission data items from the Quality Indicators section of the IRF-
PAI. To convert from using the FIM\TM\ items to using the data items
from the Quality Indicators section of the IRF-PAI, RTI first had to
identify which quality indicator data items would be the best
predictors of cost, as previously discussed. Then, RTI used CART
analysis to modify the CMG definitions to reflect the use of the
different assessment items.
To develop CMGs based on the data items from the Quality Indicators
section of the IRF-PAI, RTI used CART analysis to divide patients into
payment groups based on similarities in their clinical characteristics
and relative costs. As part of this analysis, RTI imposed certain
restraints on these groupings to decrease the resulting number of CMGs
(to ensure that the payment system did not become unduly complicated).
For a more detailed discussion of these analyses or for more
information on the development of the CMGs, we refer readers to the
technical report, ``Analyses to Inform the Potential Use of
Standardized Patient Assessment Data Elements in the Inpatient
Rehabilitation Facility Prospective Payment System'', available at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Research.html.
In developing the revised CMGs, RTI's analysis indicated that RIC
16 and RIC 17 should incorporate the CMGs shown in Table 8, based on
motor score and cognitive function, derived from the memory and
communication scores.
Table 8--CART-Based CMGs for RIC 16 (Pain Syndrome) and RIC 17 (Major Multiple Trauma Without Brain or Spinal
Cord Injury)
----------------------------------------------------------------------------------------------------------------
RIC CMG Cases Avg. cost Rule 1 Rule 2 Rule 3
----------------------------------------------------------------------------------------------------------------
16......... 1 255 $11,088.65 Motor >= 70.....
16......... 2 270 13,402.22 Motor < 70...... Motor >= 61.....
16......... 3 188 14,775.04 Motor < 61...... Cognition >= 7..
16......... 4 260 16,806.16 Motor < 61...... Cognition >= 7..
17......... 1 1149 12,911.91 Motor >= 62.....
17......... 2 1557 15,504.35 Motor < 62...... Motor >= 51.....
17......... 3 624 17,273.01 Motor < 51...... Motor >= 47.....
17......... 4 927 19,209.23 Motor < 47...... Motor >= 39.....
17......... 5 289 20,245.80 Motor < 51...... Motor < 39...... Cognition < 8.
17......... 6 205 23,465.77 Motor < 51...... Motor < 39...... Cognition >= 8.
----------------------------------------------------------------------------------------------------------------
We considered proposing to revise the CMGs for RIC 16 and RIC 17 as
shown above. However, these CMGs indicate higher costs for patients
with no cognitive impairment as compared to those with any level of
impairment. As this unexpected result may be driven by small sample
size, we proposed to combine CMG 03 and 04 for RIC 16 and to combine
CMG 05 and 06 for RIC 17 as shown in Table 9.
Table 9 contains the proposed CMGs and their respective
descriptions, including the functional status scores and age that we
proposed to use to classify discharges into CMGs. Table 9 also contains
the CMG relative weights and average length of stay values for the
CMGs. We did not propose any changes to methodology used to determine
the CMG relative weights that was finalized in the FY 2002 IRF final
rule (66 FR 41351 through 41357) and revised in the FY 2009 IRF final
rule (73 FR 46372 through 46374). For more information on the
methodology used to calculate the CMG relative weights please refer to
section IV. of this final rule.
Table 9--Revised Relative Weights and Average Length of Stay Values for the Revised Case-Mix Groups
--------------------------------------------------------------------------------------------------------------------------------------------------------
Relative weight Average length of stay
---------------------------------------------------------------------------------------
CMG CMG description (M = motor, A = No No
age) Tier 1 Tier 2 Tier 3 comorbidity Tier 1 Tier 2 Tier 3 comorbidity
tier tier
--------------------------------------------------------------------------------------------------------------------------------------------------------
0101......................... Stroke M >= 77................... 1.0570 0.9232 0.8492 0.8050 11 11 10 10
0102......................... Stroke M < 77 and M >= 68........ 1.3370 1.1678 1.0741 1.0182 13 13 12 12
0103......................... Stroke M < 68 and M >= 55........ 1.6848 1.4715 1.3535 1.2831 15 16 15 15
0104......................... Stroke M < 55 and M >= 47........ 2.1484 1.8764 1.7260 1.6361 19 20 19 19
0105......................... Stroke M < 47 and A >= 85........ 2.4137 2.1081 1.9391 1.8382 22 22 21 20
0106......................... Stroke M < 47 and A < 85......... 2.7956 2.4417 2.2460 2.1291 26 27 24 23
0201......................... Traumatic Brain Injury M >= 73... 1.2418 1.0426 0.9376 0.8708 12 12 11 11
0202......................... Traumatic Brain Injury M < 73 and 1.4929 1.2534 1.1272 1.0468 14 14 13 12
M >= 64.
0203......................... Traumatic Brain Injury M < 64 and 1.7699 1.4859 1.3363 1.2411 16 17 15 14
M >= 51.
0204......................... Traumatic Brain Injury M < 51 and 2.1753 1.8263 1.6424 1.5254 21 20 18 17
M >= 36.
0205......................... Traumatic Brain Injury M < 36.... 2.6959 2.2634 2.0355 1.8904 36 24 22 19
[[Page 38538]]
0301......................... Non-Traumatic Brain Injury M >= 1.2192 1.0096 0.9348 0.8735 11 11 11 10
70.
0302......................... Non-Traumatic Brain Injury M < 70 1.5403 1.2755 1.1810 1.1034 14 14 13 13
and M >= 57.
0303......................... Non-Traumatic Brain Injury M < 57 1.8496 1.5316 1.4182 1.3251 17 16 15 15
and M >= 45.
0304......................... Non-Traumatic Brain Injury M < 45 2.0666 1.7113 1.5846 1.4806 20 18 17 16
and A >= 79.
0305......................... Non-Traumatic Brain Injury M < 45 2.2755 1.8843 1.7447 1.6302 21 21 18 17
and A < 79.
0401......................... Traumatic Spinal Cord Injury M >= 1.2999 1.0952 1.0122 0.9370 13 12 12 11
64.
0402......................... Traumatic Spinal Cord Injury M < 1.6630 1.4011 1.2949 1.1987 15 15 15 14
64 and M >= 57.
0403......................... Traumatic Spinal Cord Injury M < 1.9672 1.6574 1.5318 1.4180 15 18 17 16
57 and M >= 46.
0404......................... Traumatic Spinal Cord Injury M < 2.6209 2.2082 2.0408 1.8892 25 24 23 21
46 and M >= 36.
0405......................... Traumatic Spinal Cord Injury M < 3.1923 2.6895 2.4857 2.3010 34 29 27 24
36 and A < 63.
0406......................... Traumatic Spinal Cord Injury M < 3.6963 3.1142 2.8782 2.6643 46 34 28 29
36 and A >= 63.
0501......................... Non-Traumatic Spinal Cord Injury 1.1291 0.9068 0.8382 0.7642 10 11 10 9
M >= 75.
0502......................... Non-Traumatic Spinal Cord Injury 1.4096 1.1322 1.0464 0.9541 14 13 12 11
M < 75 and M >= 63.
0503......................... Non-Traumatic Spinal Cord Injury 1.7905 1.4381 1.3292 1.2119 16 15 15 14
M < 63 and M >= 52.
0504......................... Non-Traumatic Spinal Cord Injury 2.2191 1.7823 1.6473 1.5020 21 19 18 17
M < 52 and M >= 44.
0505......................... Non-Traumatic Spinal Cord Injury 2.8377 2.2792 2.1065 1.9206 27 24 22 21
M < 44.
0601......................... Neurological M >= 69............. 1.3205 1.0500 0.9795 0.8873 12 12 11 10
0602......................... Neurological M < 69 and M >= 57.. 1.6324 1.2981 1.2109 1.0969 14 14 13 13
0603......................... Neurological M < 57 and M >= 47.. 1.9170 1.5244 1.4220 1.2882 16 16 15 14
0604......................... Neurological M < 47.............. 2.2218 1.7667 1.6481 1.4929 20 18 17 16
0701......................... Fracture of Lower Extremity M >= 1.1960 0.9851 0.9487 0.8595 11 11 11 10
67.
0702......................... Fracture of Lower Extremity M < 1.5308 1.2608 1.2142 1.1001 14 14 14 13
67 and M >= 55.
0703......................... Fracture of Lower Extremity M < 1.8510 1.5245 1.4682 1.3302 17 17 16 15
55 and M >= 45.
0704......................... Fracture of Lower Extremity M < 2.0790 1.7124 1.6491 1.4941 18 18 18 17
45.
0801......................... Replacement of Lower Extremity 1.0475 0.8892 0.8044 0.7437 10 10 9 9
Joint M >= 67.
0802......................... Replacement of Lower Extremity 1.2925 1.0972 0.9926 0.9176 12 12 11 11
Joint M < 67 and M >= 56.
0803......................... Replacement of Lower Extremity 1.5469 1.3132 1.1880 1.0982 15 15 13 12
Joint M < 56 and M >= 47.
0804......................... Replacement of Lower Extremity 1.8517 1.5719 1.4220 1.3146 16 17 15 15
Joint M < 47.
0901......................... Other Orthopedic M >= 69......... 1.1749 0.9376 0.8792 0.8083 11 11 10 10
0902......................... Other Orthopedic M < 69 and M >= 1.5103 1.2052 1.1302 1.0390 13 14 13 12
55.
0903......................... Other Orthopedic M < 55 and M >= 1.8117 1.4457 1.3557 1.2463 15 16 15 14
47.
0904......................... Other Orthopedic M < 47.......... 2.0393 1.6273 1.5261 1.4029 17 17 16 16
1001......................... Amputation Lower Extremity M >= 1.3231 1.1340 1.0276 0.9487 12 13 12 11
67.
1002......................... Amputation Lower Extremity M < 67 1.6372 1.4032 1.2715 1.1739 15 15 14 14
and M >= 59.
1003......................... Amputation Lower Extremity M < 59 1.8961 1.6251 1.4726 1.3596 17 16 16 15
and M >= 49.
1004......................... Amputation Lower Extremity M < 49 2.1617 1.8527 1.6788 1.5500 19 20 18 17
1101......................... Amputation Non-Lower Extremity... 1.8322 1.3022 1.3022 1.0585 15 14 13 12
1201......................... Osteoarthritis M >= 65........... 1.3071 1.0757 0.9575 0.8777 11 12 11 11
1202......................... Osteoarthritis M < 65 and M >= 49 1.6787 1.3816 1.2297 1.1273 14 15 14 13
1203......................... Osteoarthritis M < 49............ 1.9145 1.5756 1.4024 1.2857 16 16 16 15
1301......................... Rheumatoid Other Arthritis M >= 1.1111 0.9753 0.9076 0.8570 10 11 10 11
69.
1302......................... Rheumatoid Other Arthritis M < 69 1.3176 1.1567 1.0764 1.0164 12 13 12 12
and M >= 58.
1303......................... Rheumatoid Other Arthritis M < 58 1.6691 1.4652 1.3635 1.2875 13 17 14 14
and A >= 72.
1304......................... Rheumatoid Other Arthritis M < 58 1.7642 1.5487 1.4412 1.3609 14 17 15 15
and A < 72.
1401......................... Cardiac M >= 70.................. 1.1839 0.9920 0.8991 0.8023 11 11 10 9
1402......................... Cardiac M < 70 and M >= 59....... 1.4635 1.2263 1.1115 0.9918 13 13 12 11
1403......................... Cardiac M < 59 and M >= 51....... 1.7034 1.4272 1.2936 1.1544 15 15 14 13
1404......................... Cardiac M < 51................... 1.9704 1.6510 1.4964 1.3353 18 17 16 14
1501......................... Pulmonary M >= 84................ 1.0149 0.9214 0.8346 0.7907 7 10 9 9
1502......................... Pulmonary M < 84 and M >= 74..... 1.2323 1.1187 1.0133 0.9601 11 12 11 10
1503......................... Pulmonary M < 74 and M >= 59..... 1.4557 1.3215 1.1970 1.1341 13 13 12 12
1504......................... Pulmonary M < 59 and M >= 46..... 1.7464 1.5853 1.4360 1.3606 15 15 14 14
1505......................... Pulmonary M < 46................. 2.0273 1.8404 1.6670 1.5794 20 17 15 16
1601......................... Pain Syndrome M >= 70............ 1.2293 0.9242 0.8776 0.7774 10 11 10 10
1602......................... Pain Syndrome M < 70 and M >= 61. 1.5216 1.1439 1.0863 0.9622 12 12 12 11
1603......................... Pain Syndrome M < 61............. 1.8391 1.3826 1.3129 1.1630 13 15 14 13
1701......................... Major Multiple Trauma Without 1.4355 1.1154 1.0668 0.9504 14 13 12 11
Brain or Spinal Cord Injury M >=
62.
1702......................... Major Multiple Trauma Without 1.7939 1.3938 1.3330 1.1876 16 15 15 14
Brain or Spinal Cord Injury M <
62 and M >= 51.
1703......................... Major Multiple Trauma Without 2.0059 1.5585 1.4906 1.3280 17 16 16 15
Brain or Spinal Cord Injury M <
51 and M >= 47.
1704......................... Major Multiple Trauma Without 2.1848 1.6975 1.6236 1.4465 19 18 17 16
Brain or Spinal Cord Injury M <
47 and M >= 39.
1705......................... Major Multiple Trauma Without 2.4250 1.8841 1.8020 1.6055 21 21 19 17
Brain or Spinal Cord Injury M <
39.
1801......................... Major Multiple Trauma With Brain 1.1980 1.0351 0.8752 0.8233 13 11 10 10
or Spinal Cord Injury M >= 72.
1802......................... Major Multiple Trauma With Brain 1.5335 1.3250 1.1204 1.0539 14 16 12 12
or Spinal Cord Injury M < 72 and
M >= 58.
1803......................... Major Multiple Trauma With Brain 2.0608 1.7806 1.5056 1.4162 23 19 16 16
or Spinal Cord Injury M < 58 and
M >= 42.
[[Page 38539]]
1804......................... Major Multiple Trauma With Brain 2.9220 2.5248 2.1348 2.0081 34 25 23 22
or Spinal Cord Injury M < 42.
1901......................... Guillain-Barr[eacute] M >= 54.... 1.5211 1.2331 1.1228 1.0834 16 15 12 13
1902......................... Guillain-Barr[eacute] M < 54..... 3.4558 2.8014 2.5507 2.4613 39 28 27 27
2001......................... Miscellaneous M >= 70............ 1.2339 1.0047 0.9349 0.8447 11 11 10 10
2002......................... Miscellaneous M < 70 and M >= 58. 1.5240 1.2410 1.1547 1.0433 14 13 12 12
2003......................... Miscellaneous M < 58 and M >= 49. 1.7837 1.4525 1.3515 1.2211 16 15 14 14
2004......................... Miscellaneous M < 49............. 2.0373 1.6589 1.5436 1.3947 19 17 16 15
2101......................... Burns............................ 1.9058 1.5390 1.5118 1.3015 22 16 16 14
5001......................... Short-stay cases, length of stay ........ ........ ........ 0.1801 ........ ........ ........ 3
is 3 days or fewer.
5101......................... Expired, orthopedic, length of ........ ........ ........ 0.6240 ........ ........ ........ 7
stay is 13 days or fewer.
5102......................... Expired, orthopedic, length of ........ ........ ........ 1.7071 ........ ........ ........ 18
stay is 14 days or more.
5103......................... Expired, not orthopedic, length ........ ........ ........ 0.6795 ........ ........ ........ 7
of stay is 15 days or fewer.
5104......................... Expired, not orthopedic, length ........ ........ ........ 2.1069 ........ ........ ........ 21
of stay is 16 days or more.
--------------------------------------------------------------------------------------------------------------------------------------------------------
The following would be the most significant differences between the
current CMGs and the revised CMGs:
There would be fewer CMGs than before (88 instead of 92
currently).
There would be fewer CMGs in RICs 1, 2, 5, 8, 11, and 19,
while there would be more CMGs in RICs 3, 4, 10, 13, 15, 17, and 18.
A patient's age would affect assignment for CMGs in RICs
1, 3, 4, and 13 whereas it currently affects assignment for CMGs in
RICs 1, 4, and 8.
We proposed to utilize the CMGs based on the data items from the
Quality Indicators section of the IRF-PAI to classify IRF patients for
purposes of establishing payment under the IRF PPS beginning with FY
2020. We proposed to implement these revisions in a budget neutral
manner. For more information on the specific impacts of this change, we
refer readers to Table 10. We also proposed to update the CMG relative
weights and average length of stay values associated with the CMGs
based on the data items from the Quality Indicators section of the IRF-
PAI. We believe it is appropriate to update the CMGs and relative
weights for FY 2020 to better align IRF payments with the costs of
caring for IRF patients, given the new information that is captured by
the data items from the Quality Indicators section of the IRF-PAI.
Additionally, changes in treatment patterns, technology, case-mix, and
other factors affecting the relative use of resources in IRFs since the
current CMGs were last revised, likely require an update to the
classification system.
Table 10--Distributional Effects of the Changes to the CMGs
----------------------------------------------------------------------------------------------------------------
Facility classification Number of IRFs Number of % Change in
--------------------------------------------------------------------------------- cases mean payment
-------------------------------
(1) (2) (3) (4)
----------------------------------------------------------------------------------------------------------------
Total........................................................... 1,111 369,684 0
Urban unit...................................................... 702 155,121 3
Rural unit...................................................... 133 20,074 3
Urban hospital.................................................. 265 190,431 -2
Rural hospital.................................................. 11 4,058 -1
Urban For-Profit................................................ 339 185,702 -2
Rural For-Profit................................................ 37 7,388 2
Urban Non-Profit................................................ 529 137,321 2
Rural Non-Profit................................................ 84 13,338 2
Urban Government................................................ 99 22,529 3
Rural Government................................................ 23 3,406 4
Urban........................................................... 967 345,552 0
Rural........................................................... 144 24,132 2
Urban by region
Urban New England............................................... 29 15,514 -2
Urban Middle Atlantic........................................... 134 48,194 -2
Urban South Atlantic............................................ 144 69,040 0
Urban East North Central........................................ 173 46,132 3
Urban East South Central........................................ 56 24,250 -1
Urban West North Central........................................ 73 18,333 0
Urban West South Central........................................ 180 75,717 -1
Urban Mountain.................................................. 81 26,683 -1
Urban Pacific................................................... 97 21,689 4
Rural by region
Rural New England............................................... 4 1,048 -6
Rural Middle Atlantic........................................... 11 1,244 3
Rural South Atlantic............................................ 16 3,491 -1
Rural East North Central........................................ 21 3,599 2
[[Page 38540]]
Rural East South Central........................................ 21 4,174 4
Rural West North Central........................................ 21 2,829 2
Rural West South Central........................................ 40 6,765 4
Rural Mountain.................................................. 7 722 4
Rural Pacific................................................... 3 260 2
Teaching status
Non-teaching.................................................... 842 303,102 -1
Teaching........................................................ 269 66,582 2
Bed size
<25............................................................. 563 85,835 3
25-49........................................................... 314 107,858 1
50-74........................................................... 134 85,923 -1
75-99........................................................... 58 48,564 -2
100-124......................................................... 19 14,527 -2
125+............................................................ 23 26,977 -1
----------------------------------------------------------------------------------------------------------------
Table 10 shows how we estimate that the application of the
revisions to the case-mix system for FY 2020 would affect particular
groups. Table 10 categorizes IRFs by geographic location, including
urban or rural location, and location for CMS's 9 Census divisions of
the country. In addition, the table divides IRFs into those that are
separate rehabilitation hospitals (otherwise called freestanding
hospitals in this section), those that are rehabilitation units of a
hospital (otherwise called hospital units in this section), rural or
urban facilities, ownership (otherwise called for-profit, non-profit,
and government), by teaching status, and bed size. The changes to the
case-mix classification system are expected to affect the overall
distribution of payments across CMGs. Note that, because we proposed to
implement the revisions to the case-mix classification system in a
budget-neutral manner, total estimated aggregate payments to IRFs would
not be affected as a result of the revisions to the CMGs. However,
these revisions may affect the distribution of payments across CMGs.
We received 94 comments on our proposals to remove the FIM\TM\
instrument and associated Function Modifiers from the IRF-PAI beginning
with FY 2020 and to incorporate certain data items located in the
Quality Indicators section of the IRF-PAI in the IRF case-mix
classification system, which are summarized below.
Comment: Several commenters expressed support for the removal of
the FIM\TM\ and associated Function Modifier items from the IRF-PAI.
One commenter stated that collection of both sets of data items is
inefficient and takes time away from patient care and also noted that
they prefer the data items located in the Quality Indicators section of
the IRF-PAI as they are easier to score and are better understood.
Another commenter was fully supportive of this proposal, noting that it
would remove the requirement of having to report on similar data twice,
which providers have indicated is a substantial burden. This commenter
stated that they believe this proposal would result in only minor
changes to the payment system because of the similarities between the
FIM\TM\ and Quality Indicators data items and noted that there would
not be any changes to the RICs used in the IRF PPS. Additionally, this
commenter stated that the removal of the FIM\TM\ instrument is
responsive to the IMPACT Act requirement to remove duplicative or
overlapping data as soon as practicable.
Response: We appreciate the commenters' support for our proposal to
remove the FIMTM instrument and associated Function
Modifiers from the IRF-PAI and agree with the one commenter's
assessment that this proposal will not result in major changes to the
IRF case-mix classification system. We also agree with the commenter
that the proposal to remove the FIMTM instrument and
associated Function Modifiers from the IRF-PAI aligns with the overall
goals of the IMPACT Act.
Comment: While many commenters were appreciative of efforts to
reduce burden and generally supportive of future post-acute care
payment reform efforts, most commenters did not support the removal of
the FIMTM instrument and associated Function Modifiers from
the IRF-PAI, citing concerns over the incorporation of the data items
located in the Quality Indicators section of the IRF-PAI into the IRF
PPS. Several commenters stated that too little is known about the
accuracy, consistency and clinical efficacy of these data items. Many
commenters expressed concern that these items have not been
meaningfully evaluated and have not been found to be valid and reliable
measures of patients' functional status. Additionally, many commenters
stated that the data items in the Quality Indictors section of the IRF-
PAI have not been sufficiently studied, understood, or validated to be
used as the basis for a new budget neutral case-mix system. Many
commenters noted they were supportive of the objective to eliminate
duplicative data elements, and some were supportive of potentially
removing the FIMTM in the future, but many commenters stated
that finalizing the removal of the FIMTM data would be
premature at this time. Commenters expressed concerns that the data
items that we had proposed to replace the FIMTM data items
have not been proven reliable or valid for payment purposes and
requested to continue reporting data through the FIMTM
instrument.
Response: We disagree with the commenters that the data items in
the Quality Indicators section of the IRF-PAI have not been
meaningfully evaluated and have not been proven reliable and valid. The
data items and response codes located in the Quality Indicators section
of the IRF-PAI that were proposed to be incorporated into the IRF case-
mix classification system were derived from a subset of items within
the CARE Tool that were extensively tested for validity and reliability
in the IRF setting as part of the Post-Acute Care Payment Reform
Demonstration (PAC PRD). These items were developed to accurately
measure the functional and cognitive status of
[[Page 38541]]
patients across PAC settings and were found to be reliable and valid. A
description of the reliability and validity testing methodology and
results are available in several reports, including The Development and
Testing of the Continuity Assessment Record and Evaluation (CARE) Item
Set, the Final Report On Reliability Testing, and the Final Report on
CARE Item Set and Current Assessment Comparisons. These reports are
available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/CARE-Item-Set-and-B-CARE.html.
Additionally, these data items were extensively tested for payment
purposes under the IRF PPS as part of the PAC PRD. These data items
were developed in response to a mandate in Section 5008 of the Deficit
Reduction Act of 2005 and were collected for analysis under the PAC PRD
from 2008 to 2010. Analyses conducted through the PAC PRD found that
the elements of the CARE tool include proven predictors of health care
costs and utilization across PAC prospective payment systems. More
information on the PAC PRD is available on the CMS website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/Research-Reports-Items/PAC_Payment_Reform_Demo_Final.html.
In addition to this, we conducted reliability and validity testing
of the data items associated with the four IRF QRP functional outcome
measures when these measures were submitted for NQF endorsement as
discussed in the FY 2016 IRF PPS final rule (80 FR 47096 through
47120). The testing of the data elements, the scale and facility-level
data showed very good reliability and validity. We will update the
reliability and validity testing of the data items associated with the
four IRF QRP functional outcome measures, as these outcome measures are
due for maintenance of NQF endorsement in 2019.
In addition to the work conducted under the PAC PRD, RTI conducted
analysis to identify the best predictors of cost and then used CART
analysis to modify the CMG definitions to reflect the use of the
different assessment items. RTI found that the model predicting costs
using CMGs derived from the items located in the Quality Indicators
section of the IRF-PAI, based on data from FY 2017, had a slightly
higher R-squared value than models using the current CMGs which are
derived from items in the FIMTM instrument, thus indicating
that the revised CMGs more accurately predict costs than the CMGs that
are currently utilized.
Additionally, we disagree with the commenters' characterization of
this proposal as the construction of a new budget neutral case-mix
system. Instead, we proposed revisions to the case-mix system solely to
incorporate the data items from the Quality Indicators section instead
of the FIMTM instrument. We note that that we did not
propose any changes to the RICs, comorbidity tiers, or the relative
weight methodology that are currently in place, and we believe the
proposed revisions to the case-mix groups would result in minor changes
to the structure of the CMGs.
Comment: A number of commenters expressed concerns that the removal
of the FIMTM instrument could, paradoxically, increase
burden on providers and potentially worsen patient outcomes. Many
commenters noted that providers would need to invest in system changes
due to these proposals. Several commenters stated that facilities need
adequate lead time, measured in years, to change electronic medical
record systems, financial tracking and reporting systems, quality
measurement recording, and program improvement purposes and that any
regulatory burden reduction derived from eliminating duplicative
reporting would be offset by having to adapt to major changes in the
payment system. Additionally, several commenters suggested that
eliminating the FIMTM instrument to reduce burden may have
the opposite effect in light of ongoing confusion and uncertainty in
proper coding of section GG items, which are the data items in the
Quality Indicators section, and suggested that burden would increase
from education and training activities.
Response: We disagree with the suggestion that the proposed removal
of the FIMTM instrument and associated Function Modifiers
would increase administrative burden associated with Medicare data
reporting requirements or have an adverse effect on patient outcomes.
This proposal would simply remove data items from the IRF-PAI and was
proposed with a one year delayed effective date of October 1, 2019 to
allow providers time to make necessary system changes. We note that
with each assessment release, we provide free software to providers
that allows for the completion and submission of any required
assessment data. Free downloads of the Inpatient Rehabilitation
Validation and Entry (IRVEN) software product are available on the CMS
website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Software.html. Additionally, we disagree
with the commenters' suggestions that the proposal would create
additional burden on providers from training activities, as these data
items have been collected nationally for almost 2 years. We do not
believe providers will experience additional burden from the continued
reporting and collection of this subset of Quality Indicator data
items.
Comment: Several commenters supported the continued collection of
FIMTM data because the commenters said that they did not
believe that the Quality Indicator items accurately capture burden of
care. Multiple commenters noted that the Quality Indicators data items
use a different scale, and that this compressed scale may limit the
ability to capture the complexity of the sickest IRF patients.
Commenters stated that they believe the scale used for the data items
located in the Quality Indicators section of the IRF-PAI is less
sensitive than the scale used for the FIMTM items and
expressed concern that the scale does not capture a patient's true
severity of impairment. Several commenters stated the scale for the
Quality Indicator items does not have the specificity or predictability
of the FIMTM scale and expressed concern that the scale for
these items does not reflect progress between admission and discharge
in a similar manner as the FIMTM scale.
Response: We disagree with the commenters and believe that the data
items located in the Quality Indicators section of the IRF-PAI
accurately capture the functional and cognitive status of patients and
can also be used to accurately assess changes in patients' functional
status. We believe that the six level scale utilized for the data items
located in the Quality Indicators section of the IRF-PAI better
distinguishes change at the highest and lowest levels of patient
function by documenting minimal change from no change at the low end of
the scale. This is important for measuring progress in some of the most
complex cases treated in PAC settings. Additionally, we note that these
data items were developed with input from the clinical therapy
communities to better measure the change in function, regardless of the
severity of the individual's impairment. The self-care and mobility
data elements included on the IRF-PAI were selected to represent a wide
range of activity difficulty, and cover a wide range of patient
functioning, from low to high functioning. At admission, activities in
the areas of toileting hygiene, dressing,
[[Page 38542]]
bed mobility, bed and toilet transfers, and walking distinguish patient
ability. Several data elements are activities that are very challenging
for patients to complete and are frequently coded using the ``activity
not attempted codes'' at admission. Thus, these more challenging data
elements may not contribute as much to identify differences in patient
ability at admission beyond the included data elements. These more
challenging activities (for example, car transfers and 12 steps) are
important to assess at discharge as they represent daily activities
that are important for a person living in the community and are
important in differentiating patient abilities at discharge when most
patients have gained function. Overall, the inclusion of these items
allows the patient the opportunity to demonstrate gains in a variety of
functional activities and tasks. Rehabilitation care typically focuses
on several aspects of functioning, and patients may be expected to make
varying amounts of improvement, from minimal to substantial
improvement, across different functional activities.
Comment: A number of commenters noted they use the FIMTM
data for various purposes and that removing the FIMTM
instrument from the IRF-PAI would not reduce burden as providers would
still need to collect this data for internal purposes. Other commenters
indicated that FIMTM scores are sent to insurance companies
for approval of continued treatment, are used in other acute settings,
and are used by private payers to make determinations about IRF
coverage.
Response: We appreciate the commenters' concerns regarding the
various uses of the FIMTM data items outside of their use
for Medicare payment, but we note that these concerns are specific to
business decisions of individual IRF providers. For Medicare payment
purposes, we believe that the Quality Indicator items represent an
improved and more standardized way of collecting functional assessment
data on patients in the IRF setting and across PAC settings, and we
therefore also believe that collecting both the FIMTM
instrument and the Quality Indicator items on the same IRF-PAI form is
unnecessarily burdensome for providers. We certainly have no issues
with IRF providers choosing to continue to continue to collect the
FIMTM instrument data on their own, but this choice has no
bearing on our decision to remove the FIMTM items from the
IRF-PAI to minimize regulatory burden on providers.
Comment: One commenter noted that FIMTM items are
universally understood across PAC settings and suggested that we should
continue to collect the FIMTM items. This commenter also
suggested that we make the FIMTM instrument the standard
throughout all PAC areas to describe motor and cognitive function.
Response: As certain Quality Indicator data items collect data that
are similar in nature to data collected through the FIMTM
instrument and these items are currently collected in multiple PAC
settings, we believe that these items are understood by providers in
the settings in which they are currently collected and that they will
be well understood in settings in which they may be collected in the
future. We disagree with the commenter and do not believe that the
FIMTM instrument is the best instrument to use to collect
standardized patient assessment data across all PAC settings. As noted
above, the data items collected in the Quality Indicators section of
the IRF-PAI are a subset of items derived from the original CARE tool
item set that was specifically developed to measure the clinical
complexity of patients in acute care hospitals and across all four
types of PAC providers. We continue to believe that the data items
located in the Quality Indicators section of the IRF-PAI are the most
appropriate data for assessing functional status in the IRF setting and
across all PAC settings.
Comment: Several commenters suggested that we utilize a
demonstration or establish a model through CMS' Center for Medicare and
Medicaid Innovation to test the revisions to the IRF-PAI, inform future
policy recommendations, and gather additional data before making IRFs
invest in system changes for revisions to the IRF-PAI.
Response: We do not believe there is any need to test the
collection of IRF-PAI data as it would not have any impact on, or
fundamentally change, the current IRF-PAI submission process. The
Quality Indicator data items that we proposed to use to determine
Medicare payment to IRFs are already being collected on the IRF-PAI and
were originally developed and tested as part of the PAC PRD version of
the CARE item set. These items have undergone extensive testing and
validation and have been found to be accurate and valid to use for
payment purposes under the IRF PPS.
Comment: One commenter stated they were concerned that the
discontinued use of the FIMTM instrument could stymy
research and advancements in treatment and care management, as most
rehabilitation research and other Physical Medicine and Rehabilitation
(PM&R) academic papers use FIMTM data to assess function and
intervention outcomes.
Response: As noted previously, the FIMTM data items and
the Quality Indicator data items are very similar, and we therefore do
not believe that the proposed removal of the FIMTM
instrument and replacement with the Quality Indicator data will have a
substantial impact on the research being conducted in this area.
Researchers may choose to continue to use the FIMTM data
items, subject to obtaining any necessary permissions, or
alternatively, utilize the Quality Indicator data items.
Comment: One commenter inquired if preadmission screening
requirements would be updated to utilize Quality Indicator item
scoring.
Response: We do not currently require FIMTM scoring on
the preadmission screening documentation, and we will not require the
Quality Indicator item scoring on the preadmission screening
documentation either.
Comment: Several commenters expressed concerns that there are no
certification requirements and no clinician-level certification
materials for section GG items and inquired if there would be a
certification process developed for this in the future.
Response: There is currently no plan to require any certification
process for completion of the IRF-PAI. Patient assessments must be
completed in accordance with applicable federal requirements.
Comment: Commenters stated that transitioning from the
FIMTM instrument to the Quality Indicators items will take
time and sufficient training to ensure the industry understands and
consistently applies the new definitions and standards. Commenters
stated that we have not provided enough guidance to ensure the accuracy
of this data and noted that guidance received during training on the
CARE tool was inconsistent and that additional training with the CARE
tool is needed. Commenters requested that we clarify the new rules for
section GG patient assessment items, revise the IRF-PAI training manual
to reflect these clarifications, and provide more opportunities for
education and outreach to IRF providers. One commenter did not object
to the proposed removal of the FIMTM, but requested that we
develop decision trees to assist clinical teams in accurately coding
the Quality Indicators data items.
Response: We disagree with the commenters' assertions that we have
provided insufficient guidance on the
[[Page 38543]]
proper coding of this data. We are committed to providing information
and support that will allow providers to accurately interpret and
complete quality reporting items. We believe we have provided adequate
training opportunities for IRFs on coding the Quality Indicator data
items, including in-person training, webinars, on-line training and
help desk emails. We will continue to provide these types of
opportunities to the IRF community and plan to provide training and
updated educational resources regarding the Quality Indicators items
before the data items are used for payment purposes beginning on
October 1, 2019.
We finalized the collection of the Quality Indicators data items in
the FY 2016 IRF PPS final rule (80 FR 47036, 47100 through 47120).
Prior to October 1, 2016, the data collection start date, we hosted two
in-person training programs for IRFs that included coding guidance for
the Quality Indicators items followed by practice examples and a case
study so IRF clinicians could practice applying the guidance.
Additionally, we offered an IRF QRP Refresher Webinar in August 2017,
which covered coding guidance and examples for this data, and then
hosted an additional in-person training in May 2018, which also covered
coding guidance and new examples for coding this data.
The 2016, 2017, and 2018 training materials (for example, slides
and case study) are available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Reporting-Training.html. Video recordings of previous trainings
can be accessed at CMS YouTube channel at https://www.youtube.com/user/CMSHHSgov. Search for ``IRF QRP'' on the CMS You Tube channel.
A web-based training program focused on the coding of the Quality
Indicators items was published on the CMS website in December 2017.
This training module can be accessed at https://www.cms.gov/medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/gg-training/.
We also note that we receive questions about coding the items via
the IRF QRP help desk email ([email protected]), and we
encourage providers to reach out to us with any questions.
We have updated the Quality Indicators section of the IRF-PAI
Training Manual in 2016, 2017, and 2018 and incorporated coding tips
based on the questions we have received via the help desk and during
training programs. We also post on the CMS website ``Post-training
Question and Answer'' documents and ``Frequently-Asked Questions'' so
that all providers can learn from questions requested by their
colleagues. These resources are available on the IRF QRP website at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/.
We thank the commenters for their suggestion to improve training
materials by incorporating more decision trees. We will work to
incorporate this approach into our training materials.
Comment: Several commenters stated that there is considerable
confusion and uncertainty among many rehabilitation hospital clinicians
as to how to accurately and consistently score a patient's ``usual
performance'' under the Quality Indicator items and expressed concern
that the data may not be accurate due to duplication and discrepancies
in the definitions of the term ``usual performance''. One commenter
indicated that CMS has not adequately defined what it means to assess a
patient's ``usual performance'' on a Section GG item or activity and
requested that CMS clarify the definition for ``usual performance''
with specific examples.
Response: We disagree with the commenters on this point. Usual
performance has been the approach used since the development and
testing of the data elements, starting in 2006, and we believe that IRF
clinicians are able to accurately assess patients' ``usual
performance'' on the Quality Indicator items, as we have undertaken
numerous training efforts and developed comprehensive training
materials to assist providers in accurately coding these data items. We
have been pleased with the participation of IRF clinicians at the in-
person training programs and via the IRF QRP help desk since the
introduction of the Quality Indicator data elements. Our responses to
questions from the IRF QRP help desk have reflected more specific
guidance and examples related to coding usual performance. In an effort
to share this information widely with the IRF industry, we have updated
Section GG of the IRF-PAI Training Manual in 2016, 2017 and 2018 and
incorporated coding tips based on the questions we have received via
the help desk and during training programs. The IRF-PAI manual and
change tables can be found in the Download section on the IRF QRP
website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-PAI-and-IRF-QRP-Manual.html.
We also post on the CMS website ``Post-training Question and
Answer'' documents and ``Frequently-Asked Questions'' so that all
providers can learn from questions requested by their colleagues. These
resources are available on the IRF QRP website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/.
In addition, we refer readers to the most recent IRF QRP Providers
Training, held May 9-10, 2018 in Baltimore, MD. Training materials and
video recordings are available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Reporting-Training.html.
We thank the commenters for the suggestions to improve training
materials by including specific examples and appreciate the feedback on
the types of training materials that are most helpful to providers. We
will continue to offer training sessions and will work to incorporate
these approaches into our training materials. We also plan to offer
these training sessions and update training materials and educational
resources before the refinements to the case-mix classification take
effect on October 1, 2019.
Comment: One commenter sought additional information on the
expectations for capturing patient level of care and what role nursing
staff has in capturing the patient's usual performance.
Response: As noted above, the data items located in the Quality
Indicators section of the IRF-PAI and the revised CMGs have been found
to accurately reflect the relative resources needs and costliness of
patients. With regard to the expectations and role of nursing staff in
capturing patient level of care, we believe it is the responsibility of
each IRF to ensure that any staff, including nurses, that complete the
IRF-PAI assessments adhere to the coding instructions and
specifications identified in the IRF-PAI training manual for coding the
data items located in the Quality Indicators section of the IRF-PAI.
Comment: One commenter requested that we clarify how cognitive
abilities for stroke patients should be reported under the Quality
Indicator items.
Response: The reporting of cognitive ability for stroke patients
should follow the coding guidelines outlined in the IRF-PAI Training
Manual. The IRF-PAI Training Manual can be accessed on the CMS IRF QRP
website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-
[[Page 38544]]
Instruments/IRF-Quality-Reporting/IRF-PAI-and-IRF-QRP-Manual.html.
Comment: Several commenters requested that we better clarify the
instructions for completing the Quality Indicator items on the IRF-PAI.
Specifically, these commenters requested that we clarify any
differences between the reporting of the FIMTM instrument
and the Section GG items, including the timing of the data collection
(that is, the first 3 days of admission), and that we explain how
Section GG items align with other IRF requirements.
Response: We refer these commenters to Section GG in the IRF-PAI
Training Manual on the CMS IRF QRP website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-PAI-and-IRF-QRP-Manual.html for additional
information about completing the Section GG items. As we do not
understand from the comments exactly what questions these commenters
have about the Section GG items, we also encourage them to send
specific questions that they may have regarding how to report the
Section GG items or how these items align with other IRF regulations to
us at [email protected]. We will be happy to try to answer the
commenters' questions directly. We also plan to provide training and
updated educational resources regarding the Quality Indicators items
before the data items are used for payment purposes beginning on
October 1, 2019.
Comment: Several commenters specifically expressed concern with the
new cognitive function items in Section GG, stating that they believe
these items lack the appropriate sensitivity and do not capture a
complete picture of cognition, especially when compared to the legacy
cognition items from the FIMTM instrument. These commenters
said that using the new items and excluding the legacy cognitive
FIMTM items may produce an inadequate picture of patient
severity, level of impairment, and the resources needed to care for
patients. Several commenters expressed concerns with the BIMS item,
stating that the item cannot measure progress, social interaction, or
problem solving, which can lead to unsafe discharges, repeat re-
admissions, and higher SNF placement and that the item cannot define
critical deficits within cognitive domains that are useful for care
planning such as social interaction, levels of supervision, safety
considerations, and the need and use of medications. Commenters noted
that CMS is still testing these data items and recommended that these
items not be utilized until they are found to be sufficiently reliable
and valid. Another commenter indicated that work is underway to develop
better function and cognition measures and encouraged us to incorporate
the improved cognition measures into the IRF-PAI as they become
available to ensure that the breadth of cognition is captured in
patient assessment.
Response: We believe that the cognitive items including the
expression of ideas and wants, understanding verbal and non-verbal
content, and the BIMS items have been tested and have been shown to be
sensitive and valid. The reliability of these communication items was
tested in the IRF setting and results are reported in the report
entitled The Development and Testing of the Continuity Assessment
Record and Evaluation (CARE) Item Set: Final Report on Reliability
Testing Volume 2 of 3 (available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/The-Development-and-Testing-of-the-Continuity-Assessment-Record-and-Evaluation-CARE-Item-Set-Final-Report-on-Reliability-Testing-Volume-2-of-3.pdf).
This analysis indicated that the data element focused on
understanding verbal and non-verbal content and had very good
reliability with unweighted and weighted kappa values that ranged from
0.677 to 0.777. The data element focused on expression of needs also
showed very good reliability with unweighted and weighted kappa values
between 0.656-0.789.
We examined the reliability of the BIMS items in post-acute care
providers and found very good agreement with weighted kappas ranging
from 0.71 to 0.91 and unweighted kappas ranging from 0.62 to 0.86. The
kappas were highest for the ``Temporal orientation'' items at 0.86 and
above and ``Recall of three words'' at 0.89 or above for the second
recall item. The first memory item, ``Repetition of 3 words,'' was
slightly lower with kappas of 0.71.
We would also like to note that the cognitive items that were used
in RTI's CART analysis only emerged as potential splits in two RICs. As
we proposed to merge the CMGs within these RICs, these cognitive items
were not included in the proposed revised CMG definitions. We
appreciate the commenter's suggestion to incorporate improved cognition
measures into the IRF-PAI if and when they become available and will
take this into consideration in future analyses.
Comment: Several commenters expressed concerns that we have not
adequately evaluated how clinicians across the nation have been scoring
and assessing the Quality Indicators data items and suggested that we
conduct new inter-rater reliability studies to validate practice
consistency in the field before finalizing these proposals.
Response: We agree with the commenters about the importance of
reliability testing on these items to ensure that they are being scored
consistently across all IRF providers. For this reason, we examined
reliability using two distinct methods. Our initial testing focused on
within-facility testing. We requested two clinicians to assess the same
patient at the same time and independently report the patient's
ability. Our subsequent testing focused on using ``standardized
patients'' by using videotapes of persons completing daily activities
and being interviewed by a clinician. By showing the same videos to
multiple clinicians, we were able to examine the agreement of data
element coding across all the providers and across disciplines and with
coding experts. We report on the ``standardized patient'' reliability
testing in a report entitled ``Continuity Assessment Record and
Evaluation (CARE) Item Set: Video Reliability Testing'' which is
available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/Continuity-Assessment-Record-and-Evaluation-CARE-Item-Set-Video-Reliability-Testing.pdf.
When we submitted the four functional outcome measures for NQF
endorsement consideration, our NQF applications included reliability
and validity testing of the data elements, the scale and facility-level
data. The testing of the data elements, the scale and facility-level
data showed very good reliability and validity. The NQF applications
can be found at http://www.qualityforum.org/QPS/2633 and http://www.qualityforum.org/QPS/2634 and http://www.qualityforum.org/QPS/2635
and http://www.qualityforum/QPS/2636. We note that these four
functional outcome measures are due for maintenance of NQF endorsement
in 2019 and that we will submit NQF applications with updated
reliability and validity testing for the data elements, scale and
provider-level data, which will be reviewed by the NQF methods panel,
person- and family-centered care committee and the public.
Comment: Several commenters suggested that because the data items
in the FIMTM instrument and the data items collected in the
Quality Indicators section of the IRF-PAI use different scales, there
is a need to crosswalk
[[Page 38545]]
future performance to historical performance to ensure continuity in
ongoing care improvement activities. Several commenters noted there are
no available tools to crosswalk the FIMTM data items to the
CARE data items set and requested that CMS make such a tool available
so that providers can study and compare patient functional outcomes if
the FIMTM instrument is removed. A number of commenters
indicated they use national and regional benchmark data to measure
clinical outcomes and improvement efforts and recommend that CMS delay
the removal of the FIMTM instrument until benchmark data is
available for the data items located in the Quality Indicators section
of the IRF-PAI.
Response: Although the data items collected in the Quality
Indicators section of the IRF-PAI utilize different reporting
guidelines and a different scale than the FIMTM items, we
believe that the FIMTM and the Quality Indicator items are
similar enough to facilitate ongoing care improvement activities. The
items do not lend themselves to a specific cross-walk, but we do
provide national IRF Medicare data for the Functional Outcome Measures
derived from the data items located in the Quality Indicators section
of the IRF PAI in Confidential QM Reports and Provider Preview Reports
to IRFs in CASPER, so that the providers have the ability to compare
their patients' functional outcomes with those of other IRFs. The data
items located in the Quality Indicators section of the IRF-PAI have
been collected since October 1, 2016, so IRFs may use this data to
compare functional outcomes over time. By October 1, 2019, 2 years (24
months) of this data will be available. The methods used to calculate
the functional outcome measures using this data are provided in the IRF
Quality Measures User's Manual, which is available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Reporting-Program-Measures-Information-.html.
Comment: Several commenters stated that 1 year of data is too
little to be used as the basis for a new case-mix system. Many
commenters noted that providers have limited experience using the
assessment items in the Quality Indicators section of the IRF-PAI and
suggested that the data may not be accurate and valid and therefore the
revised case-mix groups may not accurately reflect patients' nursing,
therapy, cognitive and other needs. Commenters suggested that CMS
should study and evaluate the accuracy of the data before basing any
changes on it and noted CMS has not audited this data to determine if
providers are reporting the Quality Indicator items appropriately and
accurately. Many of these commenters noted that there was a 4-year
baseline of data used when the FIMTM instrument was
incorporated into the IRF PPS and that the same baseline is not present
for the analysis used to incorporate the Quality Indicators items into
the IRF PPS. Commenters suggested that we should consider delaying this
proposal until multiple years of data are available for analysis. Other
commenters suggested excluding 1 or more years of the initial data
collected from the analysis to provide a more stable foundation to
support this proposed policy change. Commenters encouraged CMS to
monitor any shifts in this data and update the model to reflect these
changes.
Response: We note that the data items in the Quality Indicators
section of the IRF-PAI have been collected for close to 2 years, and we
believe the data to be accurate and valid at this time. Additionally,
we note that we do not generally audit the FIMTM data that
is used for payment and believe it is the responsibility of the IRF to
submit accurate and valid data that adheres to the coding guidelines
detailed in the IRF-PAI training manual.
As published in the aforementioned technical report, ``Analyses to
Inform the Potential Use of Standardized Patient Assessment Data
Elements in the Inpatient Rehabilitation Facility Prospective Payment
System,'' RTI found that the model predicting costs using CMGs derived
from the items located in the Quality Indicators section of the IRF-
PAI, based on data from FY 2017, had a slightly higher R-squared value
than models using the current CMGs which are derived from items in the
FIMTM instrument, thus indicating that the revised CMGs more
accurately predict costs than the CMGs that are currently utilized.
We also note that the data items and response codes located in the
Quality Indicators section of the IRF-PAI have been collected
nationally for all IRFs since October 1, 2016. As such, the proposed
revised CMGs reflect data collected from the entire universe of
Medicare-covered inpatient rehabilitation patients, allowing for
greater precision in the analysis compared to the analysis used in the
construction of the original CMGs. The original CMGs that were
implemented at the inception of the IRF PPS were based on data from
just a sample of hospitals, which was the best available data at the
time and which contributed to the use of multiple years of data in
those analyses. As the most recently available year of national data
portrays the most recent and complete picture of patients under the IRF
PPS, we believe it was sufficient and appropriate to utilize in this
analysis.
However, we appreciate the commenters' concerns and suggestions to
incorporate multiple years of data into this analysis and conduct
monitoring activities and we will therefore ensure that we use multiple
years of data in our analysis when we incorporate the Quality Indicator
data items into the IRF case-mix classification system on October 1,
2019. We will incorporate an additional year of data into the analysis
used to update the revised CMG definitions to reflect the use of the
different assessment items. Any changes to the revised CMG definitions
will be addressed in future rulemaking prior to their implementation
beginning in FY 2020.
Comment: Several commenters requested clarifications and further
detail on how cognitive function would play a role in defining the
CMGs. Other commenters noted that current CMGs incorporate cognition
and expressed concern that cognition does not factor into the revised
CMGs. Commenters suggested that cognition is an important factor in
determining how costly a patient will be in the IRF and indicated that
not reflecting a patient's cognitive score in the CMG definitions
misses an important factor in predicting patient costs. Another
commenter recommended that we investigate whether there are floor or
ceiling effects with the proposed cognitive function items. Commenters
also requested that we allow and recognize additional cognitive
research to consider impacts on costs of care before finalizing this
policy and suggested that we conduct further study into the
relationship between cognitive function and resource use in the
inpatient rehabilitation setting. One commenter requested that the
FIMTM cognitive items be included in the CMGs to account for
the cost and impact of cognitive deficits.
Response: To clarify, a cognitive score was identified in the early
stages of the analysis for inclusion in the proposed revised CMG
definitions as a potential split for CMGs in both RIC 16 and RIC 17,
presented separately in Table 8 of the FY 2019 IRF PPS proposed rule
(83 FR 20992). Ultimately, however, we decided to propose to combine
the CMGs within these RICs because, in both cases, higher patient
cognitive deficits would have led to lower IRF payments, which we
believed would be
[[Page 38546]]
inappropriate. Also, we were concerned about this result because it was
based on a relatively small number of patients that could be
inappropriately skewing our results. As the CMGs we proposed to combine
within these RICs were only differentiated by a cognitive score, our
decision to consolidate the CMGs in these 2 RICs, resulted in the
exclusion of a cognitive score from the definitions of the revised CMGs
presented in Table 9 of the FY 2019 IRF PPS proposed rule.
We believe that the fact that patients' cognitive scores do not
show up as significant in the CART analysis in any other RICs may be
due in large part to the limitations with the cognitive items that were
proposed to be incorporated into the revised case-mix system. The
cognitive items that we used for this analysis are the best ones that
we have for use at the present time, but we will certainly consider the
incorporation of revised cognitive data items into the CMG definitions
if and when they become available in the future. We also note that,
while a cognitive score is not included in the revised CMG definitions,
the motor score may capture aspects of cognitive status as the scale
measures the need for assistance, including supervision. We will take
the commenters' concerns into consideration in future analysis.
Comment: Several commenters noted particular concerns that they had
with the proposed motor score, including concerns with the exclusion of
certain items from the score's calculation, general concerns with the
structure of the data items that were proposed for inclusion in the
motor score, and concerns with the definition of the score response
codes utilized by the data items that were proposed for inclusion in
the motor score. Commenters also requested additional information on
the predictive ability of the items that were included in the proposed
motor score. One commenter specifically requested additional
information on why item ``GG017O1--12 Steps'' was not included in the
motor score.
Response: We appreciate the commenters' concerns with the proposed
motor score. We note that RTI analyzed a range of available data to
identify the variables that were most predictive of costs in the IRF
setting. RTI's analysis shows that the correlation between the
standardized item motor score and the FIMTM motor score was
between 0.76 and 0.90 across all RICs. In addition, each of the
proposed Quality Indicators data items that were included in the motor
score were found to have statistically significant correlation with IRF
costs.
RTI's analysis of the variables that were most predictive of costs
found a higher use of ``activity not attempted codes'' for more
challenging items such as GG017O1 and found that there was less
variability overall in the score for these items across all patients on
admission, which may be due to discretion in the assessment of these
activities. Based on this finding, the more challenging items including
stairs and car transfers were not included in the motor score.
Comment: A number of commenters disagreed with the omission of
wheelchair locomotion from the motor score items that were found to
best predict costs and sought additional information on how patients
that are wheelchair dependent would be accounted for in the proposed
CMGs and what impact this would have on wheelchair-dependent patients.
One commenter noted that omitting wheelchair locomotion items from the
motor score would underestimate a patient's functional ability at
admission if the patient is more functional in a wheelchair than
walking and recommended including ``wheels 50 feet with 2 turns'' and
``wheels 150 feet'' into the motor score. One commenter noted that
omitting wheelchair items from the motor score would inappropriately
produce a higher facility payment for some patients that may be more
functional in a wheelchair than walking, as these patients' functional
ability would be underestimated based on walking items alone.
Response: We appreciate the commenters' concerns about wheelchair-
dependent patients. Patients that are considered wheelchair dependent
or are otherwise unable to walk would be accounted for in the proposed
motor score through the ``not attempted'' response codes captured
through some of the other items, especially some of the walking items
that are incorporated in the proposed motor score. We proposed to
recode any ``not attempted'' response codes to 1, the most dependent
status, because RTI's analysis of the items ``wheel 50 with two turns''
and ``wheel 150 feet with two turns'' indicated that the majority of
these items are currently coded as 1, ``dependent'' or utilized an
``activity was not attempted code''. We do not believe that the
omission of these items from the motor score would have any impact on
wheelchair dependent patients. We thank the commenters for their
suggestions and will consider the incorporation of the data items
identified above into the motor score in the future.
Comment: Commenters requested that we explain why we proposed to
use an unweighted motor score when RAND previously found that a
weighted motor score using the FIMTM items improved the
explanation of variance within each RIC.
Response: We proposed to use an unweighted motor score as our
analysis at this time does not identify any benefit from weighting the
items in the motor score. Additionally, the unweighted motor score
facilitates greater understanding among the provider community, as it
is less complex. We will take these comments into consideration in
future analysis.
Comment: Several commenters expressed concerns with the number of
claims used in the analysis and questioned if we were using
statistically sound data. Some of these commenters also suggested that
it would be more appropriate to utilize multiple years of data for this
analysis.
Response: We believe that the data utilized in this analysis was
sufficient and statistically sound. The exclusion criteria utilized in
the analysis and outlined in the technical report aligned with the
approach used by RAND when revisions to the current CMGs were finalized
in the FY 2006 IRF PPS final rule (70 FR 47892 through 47896). We
appreciate the commenter's suggestion to incorporate multiple years of
data into the analysis and will use 2 years of data (FYs 2017 and 2018)
to revise the CMG definitions prior to implementing the proposed
changes in FY 2020.
Comment: We received several comments on the proposed score
recoding methodology that was discussed in the proposed rule and in the
technical report. One commenter supported the proposed score recoding
methodology. Another commenter recommended that a value of 10 be
recoded to a 6 for the bladder continence item, and suggested that a
non-response items for the bladder item should be recoded to ``0''
instead of ``1'', noting that recoding it to ``1'' would overestimate a
patient's bladder function at admission. Another commenter stated that
they did not support the proposed score recoding methodology, and
requested that we provide additional rationale and explanation for the
methodology. Some commenters also requested that we conduct further
regression analysis to test the proposed score recoding methodology.
Additionally, one commenter expressed concern that the proposed score
recoding methodology could have significant operational impacts on
providers.
[[Page 38547]]
Response: We thank the commenters for these suggestions and will
take them into consideration in the future. We note that the proposed
methodology for recoding the ``non-response'' values aligns with the
current recoding methodology, and reflects both findings from
regression analysis and clinical input. We also note that we do not
believe that the proposed score recoding methodology could have a
significant operational impact on providers as it does not impact the
data collection or submission process of IRF-PAI data.
Comment: One commenter noted that the bladder continence and bowel
continence items use a scoring methodology where higher scores indicate
more impairment which does not align with the scoring methodology used
for the other motor items where lower scores indicate higher
impairment.
Response: As outlined in the aforementioned technical report,
available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Research.html, we proposed to reverse the
bladder continence and bowel continence responses for purposes of
determining the motor score so that the higher response codes would
reflect less impairment to be consistent with the scale used for the
other proposed motor items.
Comment: One commenter disagreed with the use of the response code
``10- the activity was not attempted due to environmental limitations''
and suggested that allowing a facility to not assess a patient due to
environmental limitations would reduce the quality of care for
patients.
Response: We appreciate the commenter's concerns but have no reason
to believe that ability to indicate why an activity was not attempted
would reduce the quality of care for patients. We note that responses
indicating an activity did not occur or was not attempted are currently
used on the IRF-PAI for items in both the FIM\TM\ Instrument and items
located in the Quality Indicators section of the IRF PAI. The addition
of this code allows for the collection of additional data indicating
why an activity was not attempted.
Comment: One commenter was generally supportive of the proposed
refinements to the CMGs but expressed concern about the proposal to
combine CMGs within RIC 16 and RIC 17, stating that fewer CMGs within
RICs may degrade the ability to quantify burden of care in sufficient
detail. Another commenter did not support the proposal to combine
certain CMGs and requested that we increase the sample size of the data
on which the analysis was conducted.
Response: As noted in the aforementioned technical report, RTI's
analysis indicated that the CMGs generated by the CART analysis for RIC
16 and RIC 17 attributed considerably higher costs for what could
amount to a small level of impairment. Given the high threshold for the
splits, the inconsistency with clinical expectations, and the low
number of observations in these RICs, we proposed to remove these
splits from the final CMG definitions. Specifically, these splits went
against clinical expectations by attributing higher payments to
beneficiaries with less impairment than to those with greater
impairment, which we believed would be inappropriate. As noted above,
we will incorporate an additional year of data into our analysis and
will revisit any changes in this proposal due to the incorporation of
additional data into the analysis in future notice and comment
rulemaking prior to implementing the revised CMG definitions beginning
in FY 2020. We appreciate the commenter's concerns and will take them
into consideration for future analysis.
Comment: Several commenters expressed concern that the new CMGs may
not accurately reflect the severity of illness of some of the most
clinically complex IRF patients, noting that there were fewer CMGs in
some RICs, thereby creating less specificity in payment determinations
for some patients. Commenters also suggested that these changes will
impact access to and quality of care for medically complex patients and
suggested that we assess the impact of these proposed changes on
patient outcomes.
Response: While the commenters are correct that, in certain RICs,
there are fewer proposed CMGs than under the current IRF case-mix
classification system, there are more proposed CMGs in other RICs. We
disagree with the commenters' concerns that the revised CMGs may not
accurately reflect resource needs for clinically complex patients. As
noted in the FY 2019 IRF PPS proposed rule (83 FR 20991 through 20992)
and the accompanying technical report, RTI utilized CART analysis on FY
2017 Medicare claims to determine the revised CMG definitions. As such,
we believe the revised CMGs reflect the severity or distinct resource
needs of the current Medicare IRF population. We believe that, if
anything, the revised CMGs will have a neutral or positive impact on
access to and quality of care for IRF patients by increasing the
accuracy of IRF payments to providers. We appreciate the commenters'
concerns and will continue to monitor the IRF data closely to ensure
that IRF payments are appropriately aligned with costs of care and that
Medicare patients continue to have appropriate access to IRF services.
Comment: Several commenters expressed concern that utilizing a
patient's usual performance instead of lowest function will make IRF
patients appear ``less severe'' and that the revised CMG definitions
will result in decreased lengths of stay and decreased payments.
Response: We agree with commenters that the scales and coding
instructions are slightly different between the data sets and that
coding a patient's usual performance instead of the patient's lowest
function may result in higher functional scores for some patients. As
noted above, we believe that the scale for the data items located in
the Quality Indicators section of the IRF-PAI is sensitive and may more
accurately reflect the costs of caring for patients.
Regarding the commenters' assertion that this proposal will lead to
shorter lengths of stay, we disagree with the commenters that the
proposal will have any substantial or long-term impact on the average
lengths of stay in the IRFs. First, we believe that these commenters
have misunderstood the purpose of the published average lengths of stay
values in the IRF PPS proposed and final rules. We note that the
average length of stay values are not prescribed lengths of stay for
patients admitted to IRFs and should not considered to be target
lengths of stay. IRFs generally have the flexibility to treat patients
for as few or as many days as they deem medically appropriate. We
encourage IRFs to admit patients for the length of time that results in
the best quality of care for the patient. The average length of stay
values are used to determine when an IRF discharge meets the definition
of a short-stay transfer.
Additionally, we believe that commenters may have been
inappropriately comparing the average lengths of stay published for the
proposed revised CMGs to the average lengths of stay for the current
CMGs. As the definitions for the proposed revised CMGs are different
than those for the current CMGs, the average length of stay values
cannot be directly compared between the two. The proposed revised CMGs
group patients differently, and therefore result in different average
length of stays for the new patient groupings. We do not believe that
the proposed revised CMGs would result in any systematic changes in
average length of stay in the IRF setting since,
[[Page 38548]]
as noted above, the average length of stay values should not considered
to be target lengths of stay.
Comment: Several commenters expressed concern that the proposed
CMGs may not, in fact, be budget neutral as proposed and requested that
we reevaluate our budget neutrality adjustment. One commenter noted
that they anticipated lower payments due to this proposal and
therefore, the proposal was not budget neutral.
Response: We disagree with the commenters' suggestions that the
proposed budget neutrality adjustment was incorrect. As stated in the
FY 2019 IRF PPS proposed rule, the proposed revisions to the IRF case-
mix classification were to be implemented in a budget neutral manner.
Thus, we proposed to apply a budget-neutrality adjustment to payments
to ensure that aggregate payments to IRFs due to the implementation of
these proposals would neither increase nor decrease overall. However,
the proposed changes would result in some redistribution of payments
among providers.
Comment: One commenter stated that we have not adequately
determined the impact of these proposed changes on patient outcomes,
including medically complex, low functioning patients and that these
types of analyses should be an essential component of the IMPACT Act's
eventual research framework before moving forward.
Response: As noted previously, the Quality Indicator data items
have been extensively tested for reliability, accuracy, and sensitivity
and were found to be reliable, accurate, and sensitive for use in the
IRF PPS. As these items are more sensitive and more accurately reflect
patients' functional status in the IRF, we believe that IRF payments
based on these items will do a better job of reflecting patients' costs
than payments based on the FIM\TM\ items. Therefore, we disagree with
the commenter and believe that, if anything, the proposed changes will
have a neutral or positive impact on access to care and outcomes for
more medically complex, low-functioning patients by paying more
accurately for these patients' care in the IRF.
Comment: One commenter requested that we adjust the classifications
and weighting factors to reflect the special care and complex medical
needs of oncology patients in the rehabilitation setting. This
commenter suggested adding additional codes to the list of impairment
group codes to better define patients with impairments due to cancer
under the RIC classification system and noted that without these
specific classifications, cancer patients may not be admitted to IRFs
due to the high costs of care for these patients.
Response: As we did not propose any changes to the RICs or
comorbidity tiers, this comment is outside the scope of the proposed
rule.
Comment: Several commenters requested more information about how
comorbid conditions will be reported for the revised case-mix
classification system and requested that we review and update the
comorbid condition code listings.
Response: As we did not propose any changes to how comorbid
conditions are to be reported or any changes to the list of comorbid
condition codes, these comments are out of scope of the proposed rule.
Comment: Many commenters noted that they were supportive of
policies in the IMPACT Act and of future Medicare payment reforms that
would move Medicare in the direction of unified post-acute care
payment. However, several of these commenters suggested that the
proposed revisions to the CMGs are inconsistent with the intent of the
IMPACT ACT. Multiple commenters noted that the IMPACT Act's core
premise is to develop a complete evidentiary basis, inform broad post-
acute care payment and delivery reform, and provide recommendations for
replacing existing payment policies based on the incorporation of
standardized patient assessment data. These commenters suggested that
finalizing the proposed policies now would be premature and recommended
that we refrain from finalizing the proposed changes at this time.
Commenters stated that because the proposal would be implemented in a
budget neutral manner, there is no financial rationale or budgetary
impact that supports moving faster than the IMPACT Act mandates. Many
commenters also stated that the functional assessment data items
located in the Quality Indicators section of the IRF-PAI were designed
for quality purposes and should not be used to develop a new payment
system.
Response: We disagree with the commenters' suggestion that these
proposals are inconsistent with the intent of the IMPACT Act and would
like to note that these policies were proposed under the authority of
section 1886(j)(2)(D), 1886(j)(2)(B), and 1886(j)(2)(C) of the Act. We
believe that the proposed policies align with the overall goals of the
IMPACT Act and are a necessary step toward a potential unified PAC PPS
in the future. We would like to note that the data items that we
proposed to incorporate into the IRF case-mix system were tested for
use in all PAC settings under the PAC PRD, and were found to be
appropriate to use for payment purposes.
We also disagree with the commenters' suggestions that the data
items located in the Quality Indicators section of the IRF-PAI were
developed for quality purposes and are therefore not suitable for use
in payment because they were developed for quality reporting purposes.
Many of these data items were derived from the original CARE Tool data
item set. The CARE Tool's development was based on certain guiding
principles, including the ability to measure the needs and clinical
characteristics of patients that were predictive of resource intensity
and that could be used to inform payment policy. While we agree with
commenters that the IMPACT Act imposed new data reporting requirements
for the purposes of the quality reporting program, it does not preclude
the use of these items for payment purposes. As noted above, these
items were developed and tested for payment purposes and were found to
be appropriate for incorporation in the IRF case-mix system. We would
also like to reiterate that we disagree with the commenter's assessment
of the proposed revisions to the CMGs as the development of a new
payment system. We believe these proposals would generate minor changes
to the current IRF case-mix classification system.
Comment: Several commenters stated that they believe that the
proposed incorporation of data items located in the Quality Indicators
section of the IRF-PAI into the IRF case-mix system conflicts with the
timelines specified in the IMPACT Act. Commenters noted that CMS and
MEDPAC are directed to submit a report to Congress by 2021 on the
findings of the IMPACT Act and to provide recommendations for replacing
existing PAC payment systems. Several commenters stated that, if we
were to move forward with finalizing the proposed changes, it would be
in direct conflict with the timelines in the IMPACT Act.
Response: We believe commenters may have misinterpreted the
reporting requirements and associated deadlines stipulated in the
IMPACT Act, as these requirements are not applicable to the proposed
removal of the FIM\TM\ instrument and associated Function Modifiers
from the IRF-PAI or the proposed incorporation of data items located in
the Quality Indicators section of the IRF-PAI into the IRF case-mix
system at this time. While these proposals are generally consistent
with the broad goal of standardizing patient assessment data collection
across PAC settings and aligning the IRF PPS with
[[Page 38549]]
other PAC payment systems, they do not implement or conflict with any
specific provision of the IMPACT Act.
Comment: Several commenters noted that they did not believe that we
have performed the thorough data analyses, testing, and engagement with
the provider community that are necessary prior to making significant
changes to the IRF-PAI and the IRF PPS. Many commenters did not support
the proposed revisions to the IRF PPS and noted they would be willing
to work with us to develop appropriate changes to payment policies in
the future. One commenter specifically expressed concern that CMS did
not seek stakeholder input through an advanced notice of public
rulemaking, similar to the process used in proposing the new SNF case-
mix classification system. Several commenters requested that we solicit
additional feedback from the stakeholder community, including convening
a technical advisory panel, to assist us in developing the proposed
changes to the IRF case-mix classification system.
Response: We are committed to engaging with the provider community
and providing information that will support a clear understanding of
our proposals and the potential impacts on providers. We would like to
note that RTI hosted a TEP in 2014 to discuss their initial research
and findings on the potential incorporation of the CARE data items into
the IRF case-mix system. Through the TEP, we received helpful feedback
on the initial research that was taken into consideration in the
development of these proposals. We appreciate the offers from
stakeholders to assist in the development of future revisions to
payment policies and we recognize the value from these partnerships. We
appreciate the request for increased engagement and will continue to
engage stakeholders in future development of payment policies. However,
we do not believe an advanced notice of proposed rulemaking would have
been necessary or that a technical advisory panel is needed at this
time as the proposed changes to the case-mix system are minor.
Comment: Several commenters expressed concern that providers needed
more time or information to model the impact of a new case-mix
classification system. Multiple commenters requested that we provide
additional information, including the algorithms and CART trees used in
the analysis to better understand how we arrived at the proposed
revisions to the CMG definitions. One commenter requested that we make
available all standardized data being collected from providers across
all settings of care. Another commenter requested that we make all data
utilized in the analysis, including the Medicare Inpatient National
Claims History, IRF-PAI data, and IRF cost reports available in full to
enable IRFs to replicate our analyses. Some commenters indicated that,
without additional data, they would not be able to provide meaningful
input on the proposed significant changes to the IRF case-mix
classification system.
Response: We believe that we released sufficient information in the
proposed rule and the accompanying technical report to enable
stakeholders to model impacts and submit meaningful comments. The
technical report, entitled ``Analyses to Inform the Potential Use of
Standardized Patient Assessment Data Elements in the Inpatient
Rehabilitation Facility Prospective Payment System,'' was released
contemporaneously with the proposed rule and describes, in detail, the
data and analysis used to construct the revised CMGs. This technical
report included the methodology used to calculate the revised
functional scores and the CMG relative weights for the revised CMG
definitions, which would allow providers to model impacts.
Additionally, the FY 2019 IRF PPS proposed rule included an impact
analysis for IRFs at a group level based on IRF provider
characteristics.
Regarding the request for additional data, we note that the release
of all standardized data being collected from providers in other
settings of care is outside the scope of the proposed rule.
Additionally, the FY 2017 IRF claims and IRF-PAI data utilized in this
analysis contain information that can be used to identify individual
Medicare beneficiaries and therefore cannot be made publicly available.
Final Decision: After careful consideration of the comments
received, we are finalizing our proposal, as discussed in section
VIII.A of this final rule, to remove the FIM\TM\ instrument and
associated Function Modifiers from the IRF-PAI beginning in FY 2020
that is, for all discharges occurring on or after October 1, 2019.
We are also finalizing our proposal to incorporate certain data
items from the Quality Indicators section of the IRF-PAI into the IRF
case-mix classification system for payment purposes beginning in FY
2020. Specifically, we are finalizing our proposal to use the Quality
Indicator data items identified in section VIII.B.2 of this final rule,
to construct the functional status scores for use in the IRF case-mix
classification system and to derive the scores for each respective
group of the functional status items by calculating the sum of the
items that constitute each functional status component.
Additionally, we are finalizing our proposal to update the score
reassignment methodology, as discussed in section VIII.B.3 of this
final rule, beginning with FY 2020, that is, for all IRF discharges
beginning on or after October 1, 2019.
We are also finalizing our proposal, as discussed in section
VIII.B.4 of this final rule, to utilize CMGs based on the data items
from the Quality Indicators section of the IRF-PAI to classify IRF
patients for purposes of establishing payment under the IRF PPS
beginning with FY 2020. However, based on public comments, we are not
finalizing the revised CMG definitions as proposed and as identified in
table 9 of this final rule. Instead, we have noted the commenters'
concerns regarding the use of one year of data and will incorporate two
full years of data (FY 2017 and FY 2018) into our analyses used to
revise the CMG definitions that will be implemented beginning in FY
2020. Any changes to the proposed CMG definitions resulting from the
incorporation of an additional year of data (FY 2018) into the analysis
will be addressed in future rulemaking prior to their implementation
beginning in FY 2020. Additionally, we will also update the relative
weights and average length of stay values associated with the revised
CMG definitions in future rulemaking. We also plan to provide training
and educational resources on the data items in the Quality Indicators
section of the IRF-PAI before this finalized policy takes effect on
October 1, 2019.
IX. Revisions to Certain IRF Coverage Requirements Beginning With FY
2019
We are committed to transforming the health care delivery system,
and the Medicare program, by putting an additional focus on patient-
centered care and working with providers and physicians to improve
patient outcomes. As an agency, we recognize it is imperative that we
develop and implement policies that allow providers and physicians to
focus the majority of their time treating patients rather than
completing paperwork. Moreover, we believe it is essential for us to
reexamine current regulations and administrative requirements, to
assure that we are not placing unnecessary burden on providers.
We believe the agency initiative of treating patients over
paperwork will improve patient outcomes, decrease provider costs, and
ensure that patients
[[Page 38550]]
and providers are making the best health care choices possible. In the
FY 2018 IRF PPS proposed rule (82 FR 20743), we included a request for
information (RFI) to solicit comments from stakeholders requesting
information on CMS flexibilities and efficiencies. The purpose of the
RFI was to receive feedback regarding ways in which we could reduce
burden for hospitals and physicians, improve quality of care, decrease
costs and ensure that patients receive the best care. We received
comments from IRF industry associations, state and national hospital
associations, industry groups representing hospitals, and individual
IRF providers in response to the solicitation. We are appreciative of
the feedback. As discussed in more detail below, we in some cases used
the commenters' specific suggestions to propose changes to regulatory
requirements to alleviate provider burden. In other cases, however, we
proposed additional changes to the regulatory requirements that we
believed would be responsive to stakeholder feedback and helpful to
providers in reducing administrative burden.
In the FY 2010 IRF PPS final rule (74 FR 39788 through 39798), we
updated the IRF coverage criteria requirements to reflect changes that
had occurred in medical practice since the IRF PPS was first
implemented in 2002. IRF care is only considered by Medicare to be
reasonable and necessary under section 1862(a)(1) of the Act if the
patient meets all of the IRF coverage requirements outlined in Sec.
412.622(a)(3), (4), and (5). Failure to meet the IRF coverage criteria
in a particular case will result in denial of the IRF claim. The IRF
coverage requirements have not been updated since they became effective
on January 1, 2010. To reduce unnecessary burden on IRF providers and
physicians, we proposed to revise the current IRF coverage criteria as
suggested by some of the comments received in response to the RFI.
Specifically, we focused on reducing medical record documentation
requirements that we believe have become overly burdensome to IRF
providers over time.
A. Changes to the Physician Supervision Requirement Beginning With FY
2019
In response to the RFI, several commenters suggested that we
consider decreasing the number of required weekly face-to-face visits
that the rehabilitation physician must complete and document in the IRF
medical record. Commenters suggested that the decrease in visits would
not only assist with reducing the medical record documentation burden
on rehabilitation physicians, but it would also afford the
rehabilitation physician more time to focus on higher-acuity, more
complex patients resulting in improved outcomes and lower readmission
rates. Additionally, we received comments suggesting that we consider
either eliminating the requirement to document post-admission physician
evaluation in the IRF medical record altogether in an effort to reduce
paperwork and duplicative requirements or that we allow the post-
admission physician evaluation to count as one of the required face-to-
face visits completed and documented by the rehabilitation physician in
the IRF medical record. We agreed with the commenters and proposed a
combination of these two suggested ideas in order to reduce unnecessary
burden on rehabilitation physicians.
Under Sec. 412.622(a)(3)(iv), for an IRF claim to be considered
reasonable and necessary under section 1862(a)(1) of the Act, there
must be a reasonable expectation at the time of the patient's admission
to the IRF that the patient requires physician supervision by a
rehabilitation physician, defined as a licensed physician with
specialized training and experience in inpatient rehabilitation. The
requirement for medical supervision means that the rehabilitation
physician must conduct face-to-face visits with the patient at least 3
days per week throughout the patient's stay in the IRF to assess the
patient both medically and functionally, as well as modify the course
of treatment as needed to maximize the patient's capacity to benefit
from the rehabilitation process. Under Sec. 412.622(a)(4)(ii), to
document that each patient for whom the IRF seeks payment is reasonably
expected to meet all of the requirements in Sec. 412.622(a)(3) at the
time of admission, the patient's medical record at the IRF must contain
a post-admission physician evaluation that meets all of the
requirements specified in the regulation. For more information, we
refer readers to the Medicare Benefit Policy Manual, chapter 1,
sections 110.1.2 and 110.2.4 (Pub. 100-02), which can be downloaded
from the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
While the purpose of the physician supervision requirement is to
ensure that the patient's medical and functional statuses are being
continuously monitored as the patient's overall plan of care is being
carried out, the purpose of the post-admission physician evaluation is
to document (in the IRF medical record) the patient's status on
admission, identify any relevant changes that may have occurred since
the preadmission screening, and provide the rehabilitation physician
with the necessary information to begin development of the patient's
overall plan of care. When the coverage criteria were initially
implemented, we believed that the post-admission physician evaluation
should not be used as a way to fulfill one of the face-to-face visits
required under Sec. 412.622(a)(3)(iv) because we considered them to be
different types of assessments. We also believed it was in the
patient's best interest to be seen by a rehabilitation physician at
least four times in the first week of the IRF admission when the
patient is in the most critical phase of their recovery process.
While we continue to believe that the post-admission physician
evaluation and the face-to-face physician visits are two different
types of assessments, after reevaluating these coverage criteria, we
believe that the rehabilitation physician should have the flexibility
to assess the patient and conduct the post-admission physician
evaluation during one of the three face-to-face physician visits
required in the first week of the IRF admission. Additionally, based on
the comments that we received in response to the RFI, we believe that
it should be the responsibility of the rehabilitation physician to use
his or her best clinical judgment to determine whether the patient
needs to be seen more than three times in the first week of the IRF
admission. Therefore, allowing these two requirements to be met (and
documented in the IRF medical record) concurrently would reduce
redundancy and regulatory burden while still ensuring adequate care to
the patient.
Therefore, we proposed to modify Sec. 412.622(a)(3)(iv) to provide
that the post-admission physician evaluation required under Sec.
412.622(a)(4)(ii) may count as one of the face-to-face physician visits
required under Sec. 412.622(a)(3)(iv) beginning with FY 2019, that is,
for all IRF discharges beginning on or after October 1, 2018. To
clarify, we did not propose to modify Sec. 412.622(a)(4)(ii),
including the 24-hour timeframe within which the post-admission
physician evaluation requirement must be completed.
We received 33 comments on the proposal to modify Sec.
412.622(a)(3)(iv) to provide that the post-admission physician
evaluation required under Sec. 412.622(a)(4)(ii) (and documented in
the IRF medical record) may count as one of the face-to-face physician
visits required under Sec. 412.622(a)(3)(iv) beginning with FY 2019,
that is, for all
[[Page 38551]]
IRF discharges beginning on or after October 1, 2018, which are
summarized below.
Comment: The majority of commenters supported our proposal.
Commenters agreed that the proposed change would provide additional
flexibility to rehabilitation physicians and reduce redundancy of
documentation requirements and regulatory burden, while still ensuring
adequate care to patients. Additionally, some commenters suggested that
they believed this proposed change would allow rehabilitation
physicians the flexibility to use their clinical judgment to determine
the need and frequency of physician visits based on each patient's
needs during the first week of admission.
Response: We appreciate the commenters' support for the proposal.
We agree that finalizing this proposal will ease administrative and
documentation burden for rehabilitation physicians.
Comment: One commenter supported the proposal, but stated that they
did not expect the proposal to produce the cost savings in Medicare
expenditures as estimated by CMS since many IRF physicians visit
patients far more frequently than the minimum three times per week.
Response: We appreciate the commenter's support for the proposal.
Based on this comment, we decided to take a more conservative approach
when estimating the burden reduction for IRFs. Therefore, we are
estimating that the rehabilitation physicians in only about half of the
IRFs would adopt this new policy change. While some IRFs may choose not
to reduce the number of physician visits, removing the need to
specifically document a visit as meeting the requirements at Sec.
412.622(a)(3) increases the flexibility that IRFs have to make these
types of decisions in the best interest of their patients and will free
up valuable physician time that can be spent on patient care.
Comment: One commenter suggested that CMS should provide greater
flexibility for IRFs to complete the post-admission physician
evaluation by allowing more lenient timeframes in which the evaluation
could be completed or should consider removing the requirement
completely. The commenter stated that the post-admission physician
evaluation is redundant with other documentation requirements such as
the pre-admission screening or the overall plan of care.
Response: We appreciate the commenters' suggestions, but we
respectfully disagree with both suggestions, as we continue to believe
that the post-admission physician evaluation, as well as the timeframe
in which it is currently required to be completed, are integral parts
of the patient's care. The purpose of the post-admission physician
evaluation is to document in the IRF medical record the patient's
status on admission, identify any relevant changes that may have
occurred since the preadmission screening, and provide the
rehabilitation physician with the necessary information to begin
development of the patients overall plan of care. We believe that
removing this requirement completely or changing the 24-hour timeframe
within which the post-admission physician evaluation must be completed,
could jeopardize initial contact with the patient and result in a
decrease in quality of care. We believe that evaluating the patient
after admission to the IRF in order to confirm that their medical and
functional status has not decreased since the pre-admission screening
is necessary to ensure the patient is still an appropriate candidate
for IRF care.
Comment: Several commenters stated that CMS should more clearly
articulate that, although we are proposing to combine the two
requirements, three face-to-face rehabilitation physician visits during
the first week of a patient's admission serves as a minimum, and
patients are entitled to additional physician visits as medically
necessary based on their rehabilitation physician's clinical judgment.
Another commenter expressed concern that loosening IRF coverage
requirements suggests that such high levels of care may not be required
by all patients who are cared for in an IRF or that the level of
resources needed to provide IRF care has decreased.
Response: To clarify, we are not limiting rehabilitation physicians
from seeing patients more than three times in the first week of a
patient's admission, nor are we limiting rehabilitation physicians from
using their best clinical judgment regarding the frequency in which
they believe patients should to be seen. Though we are finalizing our
proposal to combine these two requirements, we continue to expect that
each rehabilitation physician will exercise his or her best clinical
judgment to determine the need and frequency of rehabilitation
physician visits for a given patient.
Additionally, we respectfully disagree with the commenter that
allowing the post-admission physician evaluation to count as one of the
required face-to-face physician visits in any way implies a reduction
in the intensity of care required by IRF patients. By allowing the two
requirements to be met concurrently, we are decreasing documentation
burden on rehabilitation physicians, which will free up valuable
physician time that can be spent on patient care and oversight.
Comment: One commenter stated that after both of the requirements
were initially implemented, it was clarified through sub-regulatory
guidance that the post-admission physician evaluation and the required
face-to-face rehabilitation physician visits could not be combined. The
commenter suggested that while they support the proposal to allow the
post-admission physician evaluation to count as one of the required
face-to-face physician visits, it could also be clarified through sub-
regulatory guidance and proposing it through rulemaking was not
necessary.
Response: We appreciate the commenter's suggestion. However, since
both the post-admission physician evaluation requirement and the
required face-to-face physician visits were implemented through the
rulemaking process, we believe it is appropriate to revise our IRF
coverage policies through notice and comment rulemaking. We also want
to avoid creating any confusion for stakeholders.
Final Decision: After careful consideration of the comments we
received, we are finalizing our proposal to modify Sec.
412.622(a)(3)(iv) to provide that the post-admission physician
evaluation required under Sec. 412.622(a)(4)(ii) may count as one of
the face-to-face physician visits required under Sec.
412.622(a)(3)(iv) beginning with FY 2019, that is, for all IRF
discharges beginning on or after October 1, 2018.
B. Changes to the Interdisciplinary Team Meeting Requirement Beginning
With FY 2019
Under Sec. 412.622(a)(5), for an IRF claim to be considered
reasonable and necessary under section 1862(a)(1) of the Act, the
patient must require an interdisciplinary team approach to care, as
evidenced by documentation in the patient's medical record of weekly
interdisciplinary team meetings that meet all of the requirements
specified in the regulation. Among those requirements are that the team
meetings must be led by a rehabilitation physician and that the results
and findings of the team meetings, and the concurrence by the
rehabilitation physician with those results and findings, are retained
in the patient's medical record. For more information, we refer readers
to the Medicare Benefit Policy Manual, chapter 1, section 110.2.5 (Pub.
100-02), which can be
[[Page 38552]]
downloaded from the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
We understand that it may occasionally be difficult for the
rehabilitation physician to be physically present in the team meetings
and for that reason we have always instructed providers that the
rehabilitation physician may participate in the interdisciplinary team
meetings by telephone as long as it is clearly demonstrated in the
documentation of the IRF medical record that the meeting was led by the
rehabilitation physician. However, with the advancements in technology
since the inception of the IRF coverage criteria in 2010, we believe it
is appropriate to allow rehabilitation physicians to lead the meeting
remotely via another mode of communication, such as video or telephone
conferencing. Therefore, we proposed to amend Sec. 412.622(a)(5)(A) to
expressly provide that the rehabilitation physician may lead the
interdisciplinary meeting remotely without any additional documentation
requirements. We believe that other communication modes such as video
and telephone conferencing are acceptable ways of leading the
interdisciplinary team meeting. We believe this change will allow time
management flexibility and convenience for all rehabilitation
physicians, especially those located in rural areas who may need to
travel greater distances between facilities. We proposed for this
change to apply only to the rehabilitation physician and not the other
required interdisciplinary team meeting attendees to give IRFs time to
adapt to this change. However, we stated that we may consider expanding
this policy to include other interdisciplinary team meeting attendees
in future rulemaking. Please note that the requirement that the
rehabilitation physician must lead the interdisciplinary team meeting
will remain the same.
We received 37 comments on the proposal to amend Sec.
412.622(a)(5)(A) to expressly provide that the rehabilitation physician
may lead the interdisciplinary team meeting remotely without any
additional documentation requirements, which are summarized below.
Comment: The majority of commenters agreed with our proposal,
stating that it would decrease burdensome documentation requirements
and increase time management flexibility for rehabilitation physicians.
Response: We appreciate the support that we received from
commenters regarding this proposed change. We agree that this proposed
policy will allow rehabilitation physicians the flexibility to use
their clinical judgment regarding when it is necessary to conduct the
team meeting in-person versus when it can be conducted remotely without
hindering patient coordination and care. Additionally, we believe that
allowing the rehabilitation physician the flexibility to conduct the
interdisciplinary team meeting remotely without additional
documentation requirements will free up valuable time for the
rehabilitation physician to focus on patient care.
Comment: Some commenters stated that while they agree with allowing
the rehabilitation physician to lead the interdisciplinary team meeting
remotely without any additional documentation requirements, it should
only be allowed on a limited basis as in-person meetings enhance the
flow of communication and result in a more clearly articulated plan of
care. The commenters expressed that they believe in-person team
meetings are more effective and create a positive team involvement.
Response: We believe that each IRF should maintain the flexibility
to determine how to appropriately organize their medical staff, as well
as how to best implement a protocol for where the rehabilitation
physician leads the interdisciplinary team meeting. We are finalizing
this policy as proposed. However, we would like to clarify that this
policy in no way precludes IRFs from exercising their own discretion in
determining how best to organize their medical staff or implementing a
protocol for determining when the rehabilitation physician should lead
the interdisciplinary team meeting in person or remotely. If IRFs would
like to maintain a protocol that their rehabilitation physician must
continue to lead the interdisciplinary team meeting in-person, then we
believe they should have the flexibility to do so. Likewise, if IRFs
believe that they would like to implement a more flexible protocol for
their rehabilitation physician, we believe they should have the ability
to do so. Our purpose in revising this policy is to give rehabilitation
physicians increased flexibility for time management, as well as to
reduce documentation requirements that we believe are burdensome and
provide limited benefit to patient care and coordination.
Comment: A few commenters were not supportive of this proposal,
suggesting that in-person communication is the most effective way for
the rehabilitation physician to lead discussions regarding patient care
and coordination and that using other forms of communication such as
videoconferencing or telephone conferencing could possibly hinder the
flow of communication where critical discussions are needed. Commenters
also suggested that team members could become more easily distracted
during meetings if the rehabilitation physician was conducting the
meeting remotely. In addition, commenters suggested that although
meetings conducted with the assistance of technology have increased
throughout the medical arena, technology is not always cooperative or
reliable and could result in ineffective meetings with valuable time
lost.
Response: We appreciate the commenters' feedback and understand the
concerns that commenters have expressed. To clarify, we have always,
and continue to believe, that the role of the rehabilitation physician
during the interdisciplinary team meeting is vital to patient
coordination and care. We believe that it is of utmost importance for
the rehabilitation physician to lead the interdisciplinary team meeting
in order to make critical decisions regarding patient care. However, we
do not feel that documentation of the rehabilitation physician's
physical location during the team meeting in the IRF medical record is
needed to ensure that the rehabilitation physician is making the
decisions. We also do not believe that removal of this documentation
requirement in any way hinders patient coordination and care. For these
reasons, we have decided to finalize this policy as proposed. As noted
above, however, this policy in no way precludes IRFs from exercising
their own discretion in determining how best to organize their medical
staff or implementing a protocol for determining when the
rehabilitation physician should lead the interdisciplinary team meeting
in person or remotely. We support IRFs that want to continue requiring
the interdisciplinary team meetings to be led by the rehabilitation
physician in-person. Likewise, if IRFs would like to allow the
rehabilitation physicians more flexibility to lead the team meetings
remotely (for example, during extenuating situations only), we support
that decision as well.
Comment: A few commenters suggested that this policy should only
apply to IRFs in rural areas or underserved areas, or to small IRFs
with few staff. These commenters indicated that physician access is
frequently limited in rural and underserved areas and that this
proposal would increase access to care for patients in these areas. The
commenters suggested that for all other IRFs it should be mandatory
that
[[Page 38553]]
the rehabilitation physician leads the interdisciplinary team meeting
in-person.
Response: We appreciate the commenters' suggestion, but we believe
that implementing this policy change for some IRFs and not others would
be unduly complicated and confusing to administer, and would likely
increase administrative burden for providers rather than lessen it.
Comment: Some commenters that agreed with our proposal also
suggested that we extend the policy to allow all members of the
interdisciplinary team meeting to participate in the meeting remotely
if necessary.
Response: We appreciate the commenters' suggestion to allow
additional interdisciplinary team meeting members to participate in the
meetings remotely, if necessary. After careful consideration of the
comments, at this time, we are only applying this policy to
rehabilitation physicians. We will monitor the implementation of this
new policy and possibly consider applying this policy to other
interdisciplinary team meeting members in the future, through notice
and comment rulemaking, as appropriate.
Final Decision: After careful consideration of the comments we
received, we are finalizing our proposal to amend Sec.
412.622(a)(5)(A) to expressly provide that the rehabilitation physician
may lead the interdisciplinary meeting remotely without any additional
documentation requirements beginning with FY 2019, that is, for all IRF
discharges beginning on or after October 1, 2018. We also note that
this policy in no way precludes IRFs from exercising their own
discretion in determining how best to organize their medical staff or
implementing a protocol for determining when the rehabilitation
physician should lead the interdisciplinary team meeting in person or
remotely.
C. Changes to the Admission Order Documentation Requirement Beginning
With FY 2019
In response to the RFI, several commenters suggest that in general,
we should consider eliminating duplicative requirements. Commenters
stated that duplicative requirements placed unnecessary administrative
burden on facilities trying to make sure they comply with each nuance
of each requirement. We agreed with the commenters, and for that reason
we proposed to remove Sec. 412.606(a) as we believe that IRFs are
already required to fulfill this requirement under Sec. Sec.
482.12(c), 482.24(c), and 412.3.
Under Sec. 412.606(a), at the time that each Medicare Part A FFS
patient is admitted, the IRF must have physician orders for the
patient's care during the time the patient is hospitalized. For more
information, we refer readers to the Medicare Benefit Policy Manual,
chapter 1, section 110.1.4 (Pub. 100-02), which can be downloaded from
the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
Additionally, under Sec. 412.3(a) of the hospital payment
requirements, for the purposes of payment under Medicare Part A, an
individual is considered an inpatient of a hospital, including a
critical access hospital, if formally admitted as an inpatient under an
order for inpatient admission by a physician or other qualified
practitioner in accordance with Sec. Sec. 412.3, 482.24(c), 482.12(c),
and 485.638(a)(4)(iii) for a critical access hospital.
In an effort to reduce duplicative requirements, we believe that if
we remove the admission order documentation requirement at Sec.
412.606(a), this requirement would continue to be appropriately
addressed through the enforcement of Sec. 482.12(c) and Sec.
482.24(c) of the hospital conditions of participation (CoPs), as well
as the hospital admission order payment requirements at Sec. 412.3.
IRFs are responsible for meeting all of the inpatient hospital CoPs and
the hospital admission order payment requirements at Sec. 412.3, and,
therefore, we believe that by removing the admission order
documentation requirement at Sec. 412.606(a), we would be reducing
both regulatory redundancy as well as administrative burden.
Therefore, we proposed to amend Sec. 412.606(a) to remove the
admission order documentation requirement beginning with FY 2019, that
is, for all IRF discharges beginning on or after October 1, 2018. IRFs
would continue to meet the requirements at Sec. Sec. 482.12(c),
482.24(c), and 412.3.
We received 21 comments on the proposal to amend Sec. 412.606(a)
to remove the admission order documentation requirement, which are
summarized below.
Comment: All of the comments that we received regarding the
proposal to amend Sec. 412.606(a) to remove the admission order
documentation requirement were supportive. The commenters agreed with
our assessment that the regulations currently have duplicative
admission order requirements for IRFs. Commenters agreed that, if we
remove the admission order documentation requirement at Sec.
412.606(a), the admission order requirement would continue to be
addressed through the enforcement of the hospital conditions of
participation.
Response: We appreciate the support from the commenters regarding
the removal of the admission order documentation requirement at Sec.
412.606(a). We believe that removal of this duplicative requirement
will reduce unnecessary administrative burden on IRFs.
Comment: One commenter suggested that CMS remove the reference to
Sec. 412.3 as a requirement that IRFs will continue to be required to
meet for the purposes of admission orders, as we proposed to revise
that requirement in the FY 2019 IPPS/LTCH proposed rule to no longer
require a written inpatient admission order to be present in the
medical record as a specific condition of Medicare Part A payment.
Response: We respectfully disagree with the commenters' suggestion
to remove the reference at Sec. 412.3 as a requirement that IRFs will
need to meet. While we proposed revisions to the language at Sec.
412.3 in the FY 2019 IPPS/LTCH proposed rule (83 FR 20447 through
20448), we did not propose to remove the admission order requirement
completely. Therefore, IRFs must still meet the requirements at Sec.
412.3 as well as Sec. Sec. 482.12(c) and 482.24(c). We are finalizing
our proposal to remove the admission order requirement at Sec.
412.606(a) because it is duplicative.
Final Decision: After careful consideration of the comments we
received, we are finalizing our proposal to amend Sec. 412.606(a) to
remove the admission order documentation requirement beginning with FY
2019, that is, for all IRF discharges beginning on or after October 1,
2018. IRFs will continue to meet the requirements at Sec. Sec.
482.12(c), 482.24(c), and 412.3.
D. Summary of Comments Regarding Additional Changes to the Physician
Supervision Requirement
As discussed in section VIII.A of the proposed rule, under Sec.
412.622(a)(3)(iv), for an IRF claim to be considered reasonable and
necessary under section 1862(a)(1) of the Act, there must be a
reasonable expectation at the time of the patient's admission to the
IRF that the patient requires physician supervision by a rehabilitation
physician, defined as a licensed physician with specialized training
and experience in inpatient rehabilitation. The requirement for medical
supervision means that the rehabilitation physician must conduct face-
to-face visits with the patient at least 3 days per week throughout the
[[Page 38554]]
patient's stay in the IRF to assess the patient both medically and
functionally, as well as to modify the course of treatment as needed to
maximize the patient's capacity to benefit from the rehabilitation
process. For more information, we refer readers to the Medicare Benefit
Policy Manual, chapter 1, section 110.2.4 (Pub. 100-02), which can be
downloaded from the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
When the IRF coverage criteria were initially implemented in 2010,
we believed that the rehabilitation physician visits should be
completed face-to-face to ensure that the patient receives the most
comprehensive in-person care by a rehabilitation physician throughout
the IRF stay.
As part of our efforts to assist in reducing unnecessary regulatory
burden on IRFs, this is an issue we would like to further explore. We
solicited public comments in the FY 2019 IRF PPS proposed rule (83 FR
20997 through 20998) on whether the rehabilitation physician should
have the flexibility to determine that some of the IRF visits can be
appropriately conducted remotely via another mode of communication,
such as video or telephone conferencing. Given the level of complexity
of IRF patients, we had some concerns about whether this approach would
have an impact on the quality of care provided to IRF patients. To
maintain the hospital level of care that IRF patients require, we would
continue to expect that the majority of IRF physician visits would
continue to be performed face-to-face. However, we were interested in
feedback from stakeholders on whether we should allow a limited number
of visits to be conducted remotely. In order to better assist us in
balancing the needs of the patient, as well as retaining the hospital
level quality of care provided in an IRF with the goal of reducing the
regulatory burden on rehabilitation physicians, we sought feedback from
stakeholders about potentially amending the face-to-face visit
requirement for rehabilitation physicians. Specifically, we sought
feedback regarding the following:
Do stakeholders believe that the rehabilitation physician
would be able to fully assess both the medical and functional needs and
progress of the patient remotely?
Would this assist facilities in rural areas where it may
be difficult to employ an abundance of physicians?
Do stakeholders believe that assessing the patient
remotely would affect the quality or intensity of the physician visit
in any way?
How many and what types of visits do stakeholders believe
should be able to be performed remotely?
From an operational standpoint, how would the remote visit
work?
What type of clinician would need to be present in the
room with the patient while the rehabilitation physician was in a
remote location?
Thus, to assist us in generating ideas and information for
analyzing potential refinements in this area, we specifically solicited
public comments from stakeholders on whether the rehabilitation
physician should have the flexibility to determine that some of the IRF
visits can be appropriately conducted remotely via another mode of
communication, such as video or telephone conferencing, while
maintaining a hospital level high quality of care for IRF patients.
We received 22 comments in response to our solicitation. We
appreciate the commenters' responses to this solicitation and will take
them into consideration for possible future policy development.
E. Summary of Comments Regarding Changes to the Use of Non-Physician
Practitioners in Meeting the Requirements Under Sec. 412.622(a)(3),
(4), and (5)
Several of the requirements under Sec. 412.622(a)(3), (4), and (5)
require documentation that a rehabilitation physician, defined as a
licensed physician with specialized training and experience in
inpatient rehabilitation, visited each patient admitted to an IRF and
performed an assessment of the patient. For example, under Sec.
412.622(a)(3)(iv), for an IRF claim to be considered reasonable and
necessary under section 1862(a)(1) of the Act, there must be a
reasonable expectation at the time of the patient's admission to the
IRF that the patient requires physician supervision by a rehabilitation
physician. The requirement for medical supervision means that the
rehabilitation physician must conduct face-to-face visits with the
patient at least 3 days per week throughout the patient's stay in the
IRF to assess the patient both medically and functionally, as well as
to modify the course of treatment as needed to maximize the patient's
capacity to benefit from the rehabilitation process. For more
information, please refer to the Medicare Benefit Policy Manual,
chapter 1, section 110.2.4 (Pub. 100-02), which can be downloaded from
the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
In addition, under Sec. 412.622(a)(4)(ii), to document that each
patient for whom the IRF seeks payment is reasonably expected to meet
all of the requirements in Sec. 412.622(a)(3) at the time of
admission, the patient's medical record at the IRF must contain a post-
admission physician evaluation that must, among other requirements, be
completed by a rehabilitation physician within 24 hours of the
patient's admission to the IRF. For more information, we refer readers
to the Medicare Benefit Policy Manual, chapter 1, section 110.1.2 (Pub.
100-02), which can be downloaded from the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
In the feedback that we received in response to the RFI, it was
suggested that we consider amending the requirements in Sec.
412.622(a)(3)(iv) and Sec. 412.622(a)(4)(ii) to enable IRFs to expand
their use of non-physician practitioners (physician assistants and
nurse practitioners) to fulfill some of the requirements that
rehabilitation physicians are currently required to complete. The
commenters suggested that expanding the use of non-physician
practitioners in meeting some of the IRF requirements would ease the
documentation burden on rehabilitation physicians.
In exploring this issue, we had questions about whether non-
physician practitioners have the specialized training in inpatient
rehabilitation that would enable them to adequately assess the
interaction between patients' medical and functional care needs in an
IRF. Another concern that had been raised regarding this issue, was
whether IRF patients will continue to receive the hospital level and
quality of care that is necessary to treat such complex conditions.
To better assist us in balancing the needs of the patient with the
desire to reduce the regulatory burden on rehabilitation physicians, in
the FY 2019 IRF PPS proposed rule (83 FR 20998 through 20999), we
specifically solicited public comments from stakeholders about
potentially allowing IRFs to expand their use of non-physician
practitioners to fulfill some of the requirements that rehabilitation
physicians are currently required to complete. Specifically, we sought
feedback regarding the following:
Do non-physician practitioners have the specialized
training in rehabilitation that they need to have to
[[Page 38555]]
assess IRF patients both medically and functionally?
How would the non-physician practitioner's credentials be
documented and monitored to ensure that IRF patients are receiving high
quality care?
Are non-physician practitioners required to do rotations
in inpatient rehabilitation facilities as part of their training, or
could this be added to their training programs in the future?
Do stakeholders believe that utilizing non-physician
practitioners to fulfill some of the requirements that are currently
required to be completed by a rehabilitation physician would have an
impact of the quality of care for IRF patients?
Thus, to assist us in generating ideas and information for
analyzing potential refinements in this area, we specifically solicited
public comments from stakeholders on the ways in which the role of non-
physician practitioners could be expanded in the IRF setting while
maintaining a hospital level high quality of care for IRF patients.
We received 39 comments in response to our solicitation. We
appreciate the commenters' responses to this solicitation and will take
them into consideration for future possible policy development.
X. Updates to the IRF Quality Reporting Program (QRP)
A. Background
The Inpatient Rehabilitation Facility Quality Reporting Program
(IRF QRP) is authorized by section 1886(j)(7) of the Act, and it
applies to freestanding IRFs, as well as inpatient rehabilitation units
of hospitals or critical access hospitals (CAHs) paid by Medicare under
the IRF PPS. Under the IRF QRP, the Secretary reduces the annual
increase factor for discharges occurring during such fiscal year by 2
percentage points for any IRF that does not submit data in accordance
with the requirements established by the Secretary. For more
information on the background and statutory authority for the IRF QRP,
we refer readers to the FY 2012 IRF PPS final rule (76 FR 47873 through
47874), the CY 2013 Hospital Outpatient Prospective Payment System/
Ambulatory Surgical Center (OPPS/ASC) Payment Systems and Quality
Reporting Programs final rule (77 FR 68500 through 68503), the FY 2014
IRF PPS final rule (78 FR 47902), the FY 2015 IRF PPS final rule (79 FR
45908), the FY 2016 IRF PPS final rule (80 FR 47080 through 47083), the
FY 2017 IRF PPS final rule (81 FR 52080 through 52081), and the FY 2018
IRF PPS final rule (82 FR 36269 through 36270).
Although we have historically used the preamble to the IRF PPS
proposed and final rules each year to remind stakeholders of all
previously finalized program requirements, we have concluded that
repeating the same discussion each year is not necessary for every
requirement, especially if we have codified it in our regulations.
Accordingly, the following discussion is limited as much as possible to
a discussion of our proposals, responses to comments on those
proposals, and policies we are finalizing for future years of the IRF
QRP after consideration of the comments, and represents the approach we
intend to use in our rulemakings for this program going forward.
B. General Considerations Used for the Selection of Measures for the
IRF QRP
1. Background
For a detailed discussion of the considerations we historically
used for the selection of IRF QRP quality, resource use, and other
measures, we refer readers to the FY 2016 IRF PPS final rule (80 FR
47083 through 47084).
Comment: Several commenters offered support, suggestions for
improvement, and concerns about the implementation of the IMPACT Act.
Some commenters requested greater stakeholder engagement, including IRF
involvement in the testing of Standardized Patient Assessment Data
Elements (SPADE), and that CMS provide publicly available cross-setting
data on SPADEs. One commenter recommended that quality measurement (QM)
and SPADE development be suspended until QMs are standardized and
interoperable for all post-acute care (PAC) sites, measures are NQF
endorsed for their setting, SPADE provides evidence that it predicts
costs and/or improves quality, and additional training materials and
specifications are provided.
Response: We appreciate the comments, and we will take them into
account as we engage in future quality measure and SPADE development
for the IRF QRP. For a discussion of the IMPACT Act, the selection of
IRF QRP measures, and SPADEs, we refer readers to the FY 2016 IRF PPS
final rule (80 FR 47083 through 47084) and the FY 2018 IRF PPS final
rule (82 FR 36270 through 36276) respectively.
2. Accounting for Social Risk Factors in the IRF QRP
In the FY 2018 IRF PPS final rule (82 FR 36273 through 36274), we
discussed the importance of improving beneficiary outcomes including
reducing health disparities. We also discussed our commitment to
ensuring that medically complex patients, as well as those with social
risk factors, receive excellent care. We discussed how studies show
that social risk factors, such as being near or below the poverty level
as determined by HHS, belonging to a racial or ethnic minority group,
or living with a disability, can be associated with poor health
outcomes and how some of this disparity is related to the quality of
health care.\3\ Among our core objectives, we aim to improve health
outcomes, attain health equity for all beneficiaries, and ensure that
complex patients as well as those with social risk factors receive
excellent care. Within this context, reports by the Office of the
Assistant Secretary for Planning and Evaluation (ASPE) and the National
Academy of Medicine have examined the influence of social risk factors
in our value-based purchasing programs.\4\ As we noted in the FY 2018
IRF PPS final rule (82 FR 36273 through 36274), ASPE's report to
Congress, which was required by the IMPACT Act, found that, in the
context of value-based purchasing programs, dual eligibility was the
most powerful predictor of poor health care outcomes among those social
risk factors that they examined and tested. ASPE is continuing to
examine this issue in its second report required by the IMPACT Act,
which is due to Congress in the fall of 2019. In addition, as we noted
in the FY 2018 IPPS/LTCH PPS final rule (82 FR 38428), the National
Quality Forum (NQF) undertook a 2-year trial period in which certain
new measures and measures undergoing maintenance review have been
assessed to determine if risk adjustment for social risk factors is
appropriate for these measures.\5\ The trial period ended in April 2017
and a final report is available at http://www.qualityforum.org/SES_Trial_Period.aspx. The trial concluded that
[[Page 38556]]
``measures with a conceptual basis for adjustment generally did not
demonstrate an empirical relationship'' between social risk factors and
the outcomes measured. This discrepancy may be explained in part by the
methods used for adjustment and the limited availability of robust data
on social risk factors. NQF has extended the socioeconomic status (SES)
trial,\6\ allowing further examination of social risk factors in
outcome measures.
---------------------------------------------------------------------------
\3\ See, for example, United States Department of Health and
Human Services. ``Healthy People 2020: Disparities. 2014,'' http://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities or National Academies of Sciences, Engineering, and
Medicine. Accounting for Social Risk Factors in Medicare Payment:
Identifying Social Risk Factors. Washington, DC: National Academies
of Sciences, Engineering, and Medicine 2016.
\4\ Department of Health and Human Services Office of the
Assistant Secretary for Planning and Evaluation (ASPE), ``Report to
Congress: Social Risk Factors and Performance Under Medicare's
Value-Based Purchasing Programs.'' December 2016, https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
\5\ Available at http://www.qualityforum.org/SES_Trial_Period.aspx.
\6\ Available at: http://www.qualityforum.org/SES_Trial_Period.aspx.
---------------------------------------------------------------------------
In the FY/CY 2018 proposed rules for our quality reporting and
value-based purchasing programs, we solicited feedback on which social
risk factors provide the most valuable information to stakeholders and
the methodology for illuminating differences in outcomes rates among
patient groups within a provider that would also allow for a comparison
of those differences, or disparities, across providers. Feedback we
received across our quality reporting programs included encouraging CMS
to explore whether factors that could be used to stratify or risk
adjust the measures (beyond dual eligibility); to consider the full
range of differences in patient backgrounds that might affect outcomes;
to explore risk adjustment approaches; and to offer careful
consideration of what type of information display would be most useful
to the public.
We also sought public comment on confidential reporting and future
public reporting of some of our measures stratified by patient dual
eligibility. In general, commenters noted that stratified measures
could serve as tools for hospitals to identify gaps in outcomes for
different groups of patients, improve the quality of health care for
all patients, and empower consumers to make informed decisions about
health care. Commenters encouraged CMS to stratify measures by other
social risk factors such as age, income, and educational attainment.
With regard to value-based purchasing programs, commenters also
cautioned to balance fair and equitable payment while avoiding payment
penalties that mask health disparities or discouraging the provision of
care to more medically complex patients. Commenters also noted that
value-based payment program measure selection, domain weighting,
performance scoring, and payment methodology must account for social
risk.
As a next step, we are considering options to improve health
disparities among patient groups within and across hospitals by
increasing the transparency of disparities, as shown by quality
measures. We also are considering how this work applies to other CMS
quality programs in the future. We refer readers to the FY 2018 IPPS/
LTCH PPS final rule (82 FR 38403 through 38409) for more details where
we discuss the potential stratification of certain Hospital Inpatient
Quality Reporting Program outcome measures. Furthermore, we continue to
consider options to address equity and disparities in our value-based
purchasing programs.
We plan to continue working with ASPE, the public, and other key
stakeholders on this important issue to identify policy solutions that
achieve the goals of attaining health equity for all beneficiaries and
minimizing unintended consequences.
Comment: Many commenters supported the future implementation of a
strategy to account for social risk factors in the IRF QRP that
includes risk stratification by race, ethnicity, geographic area, sex,
and disability. The commenters also suggested that CMS consider the
role of primary language and family, caregiver and community support in
developing this strategy.
Response: We thank the commenters for their comments and will take
these comments into account as we further consider how to appropriately
account for social risk factors in the IRF QRP. We also refer the
reader to the FY 2018 IRF PPS final rule (82 FR 36273 through 36274),
where we discussed in depth many of the issues raised by these
commenters.
C. New Removal Factor for Previously Adopted IRF QRP Measures
As part of our Meaningful Measures Initiative, discussed in section
D.1. of the Executive Summary of this final rule, we strive to put
patients first, ensuring that they, along with their clinicians, are
empowered to make decisions about their own healthcare using data-
driven information that is increasingly aligned with a parsimonious set
of meaningful quality measures. We began reviewing the IRF QRP's
measures in accordance with the Meaningful Measures Initiative, and we
are working to identify how to move the IRF QRP forward in the least
burdensome manner possible, while continuing to incentivize improvement
in the quality of care provided to patients.
Specifically, we believe the goals of the IRF QRP and the measures
used in the program cover most of the Meaningful Measures Initiative
priorities, including making care safer, strengthening person and
family engagement, promoting coordination of care, promoting effective
prevention and treatment, and making care affordable.
We also evaluated the appropriateness and completeness of the IRF
QRP's current measure removal factors. We have previously finalized
that we would use notice and comment rulemaking to remove measures from
the IRF QRP based on the following factors: \7\
---------------------------------------------------------------------------
\7\ We refer readers to the FY 2013 CY 2013 Hospital Outpatient
Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC)
Payment Systems and Quality Reporting Programs final rule (77 FR
45194 through 45195) and FY 2018 IRF PPS final rule (82 FR 36276)
for more information on the factors we consider for removing
measures and standardized patient assessment data.
---------------------------------------------------------------------------
Factor 1. Measure performance among IRFs is so high and
unvarying that meaningful distinctions in improvements in performance
can no longer be made.
Factor 2. Performance or improvement on a measure does not
result in better patient outcomes.
Factor 3. A measure does not align with current clinical
guidelines or practice.
Factor 4. A more broadly applicable measure (across
settings, populations, or conditions) for the particular topic is
available.
Factor 5. A measure that is more proximal in time to
desired patient outcomes for the particular topic is available.
Factor 6. A measure that is more strongly associated with
desired patient outcomes for the particular topic is available.
Factor 7. Collection or public reporting of a measure
leads to negative unintended consequences other than patient harm.
We continue to believe these measure removal factors are
appropriate for use in the IRF QRP. However, even if one or more of the
measure removal factors applies, we might nonetheless choose to retain
the measure for certain specified reasons. Examples of such instances
could include when a particular measure addresses a gap in quality that
is so significant that removing the measure could in turn result in
poor quality, or in the event that a given measure is statutorily
required. We note further that, consistent with other quality reporting
programs, we apply these factors on a case-by-case basis.
In the FY 2019 IRF PPS proposed rule, we proposed to adopt an
additional factor to consider when evaluating measures for removal from
the IRF QRP measure set:
Factor 8. The costs associated with a measure outweigh the benefit
of its continued use in the program.
[[Page 38557]]
As we discussed in section D.1. of the Executive Summary of this
final rule, in furtherance of our new Meaningful Measures Initiative,
we are engaging in efforts to ensure that the IRF QRP measure set
continues to promote improved health outcomes for beneficiaries while
minimizing the overall costs associated with the program. We believe
these costs are multifaceted and include not only the burden associated
with reporting, but also the costs associated with implementing and
maintaining the program. We have identified several different types of
costs, including, but not limited to: (1) Provider and clinician
information collection burden and burden associated with the
submitting/reporting of quality measures to CMS; (2) the provider and
clinician cost associated with complying with other programmatic
requirements; (3) the provider and clinician cost associated with
participating in multiple quality programs, and tracking multiple
similar or duplicative measures within or across those programs; (4)
the cost to CMS associated with the program oversight of the measure
including measure maintenance and public display; and (5) the provider
and clinician cost associated with compliance to other federal and/or
state regulations (if applicable).
For example, it may be needlessly costly and/or of limited benefit
to retain or maintain a measure which our analyses show no longer
meaningfully supports program objectives (for example, informing
beneficiary choice). It may also be costly for health care providers to
track confidential feedback, preview reports, and publicly reported
information on a measure where we use the measure in more than one
program. We may also have to expend unnecessary resources to maintain
the specifications for the measure, including the tools needed to
collect, validate, analyze, and publicly report the measure data.
Furthermore, beneficiaries may find it confusing to see public
reporting on the same measure in different programs.
When these costs outweigh the evidence supporting the continued use
of a measure in the IRF QRP, we believe it may be appropriate to remove
the measure from the program. Although we recognize that one of the
main goals of the IRF QRP is to improve beneficiary outcomes by
incentivizing health care providers to focus on specific care issues
and making public data related to those issues, we also recognize that
those goals can have limited utility where, for example, the publicly
reported data is of limited use because it cannot be easily interpreted
by beneficiaries and used to influence their choice of providers. In
these cases, removing the measure from the IRF QRP may better
accommodate the costs of program administration and compliance without
sacrificing improved health outcomes and beneficiary choice.
We proposed that we would remove measures based on this factor on a
case-by-case basis. We might, for example, decide to retain a measure
that is burdensome for health care providers to report if we conclude
that the benefit to beneficiaries is so high that it justifies the
reporting burden. Our goal is to move the program forward in the least
burdensome manner possible, while maintaining a parsimonious set of
meaningful quality measures and continuing to incentivize improvement
in the quality of care provided to patients.
We invited public comment on our proposal to adopt an additional
measure removal Factor 8. The costs associated with a measure outweigh
the benefit of its continued use in the program.
Comment: Several commenters supported the proposal to add measure
removal Factor 8. The costs associated with a measure outweigh the
benefit of its continued use in the program. Commenters appreciated the
consideration of costs beyond those associated with data collection and
submission.
Response: We appreciate the support of the addition of this measure
removal factor for the IRF QRP.
Comment: A few commenters had concerns about the new measure
removal Factor 8. Some commenters suggested that CMS should involve
stakeholders when determining if Factor 8 applies to a measure, to get
input about whether clinicians or patients believe a measure is
important. One commenter requested clarification about the methods or
criteria used to assess when the measure cost or burden outweighs the
benefits of retaining it.
Response: We appreciate commenters' concerns about the new measure
removal factor. We value transparency in our processes, and continually
seek stakeholder input through education and outreach sessions, other
webinars, rulemaking, and other collaborative engagements with
stakeholders. We agree with commenters that benefits can be difficult
to define and that various stakeholders may have different perspectives
on these benefits. Because of these challenges, we intend to evaluate
each measure on a case-by-case basis, while considering input from a
variety of stakeholders, including, but not limited to: Patients,
caregivers, patient and family advocates, providers, provider
associations, healthcare researchers, data vendors, and other
stakeholders with insight into the benefits and costs (financial and
otherwise) of maintaining the specific measure in the IRF QRP.
With regard to the request for clarification about criteria used to
assess costs and burden, in the FY 2019 IRF PPS proposed rule (83 FR
21000 through 21001), we provided examples of five different costs that
could be considered in this proposed measure removal factor. We intend
to assess the costs and benefits to all program stakeholders, including
but not limited to, those listed above. We intend to balance the costs
with the benefits to a variety of stakeholders. These stakeholders
include, but are not limited to, patients and their families or
caregivers, providers, the healthcare research community, healthcare
payers, and patient and family advocates. Because for each measure the
relative benefit to each stakeholder may vary, we believe that the
benefits to be evaluated for each measure are specific to the measure
and the original rationale for including the measure in the program.
Final Decision: After consideration of the public comments, we are
finalizing our proposal to add the IRF QRP measure removal Factor 8.
The costs associated with a measure outweigh the benefit of its
continued use in the program.
We proposed to revise Sec. 412.634(b)(2) of our regulations to
codify both the removal factors we have previously finalized for the
IRF QRP, as well as the new measure removal factor that we are
finalizing in this final rule. We also proposed to remove the reference
to the payment impact from the heading of Sec. 412.634(b) and, as
discussed more fully in section X.J. of this final rule, remove the
language in current Sec. 412.634(b)(2) related to the 2 percentage
point payment reduction because that payment reduction is also
addressed at Sec. 412.624(c)(4).
We did not receive any public comments on our proposals to update
to the IRF QRP regulatory text.
Final Decision: We are finalizing the codification of the IRF QRP
measure removal factors at Sec. 412.634(b)(2) and the updates to the
regulatory text at Sec. 412.634(b). We are also making minor
grammatical edits to the IRF QRP measure removal factor language to
align with the language of other programs.
[[Page 38558]]
D. Quality Measures Currently Adopted for the FY 2020 IRF QRP
The IRF QRP currently has 18 measures for the FY 2020 program year,
which are outlined in Table 11.
Table 11--Quality Measures Currently Adopted for the FY 2020 IRF QRP
------------------------------------------------------------------------
Short name Measure name and data source
------------------------------------------------------------------------
IRF-PAI
------------------------------------------------------------------------
Pressure Ulcer.................... Percent of Residents or Patients
With Pressure Ulcers That Are New
or Worsened (Short Stay) (NQF
#0678) *.
Pressure Ulcer/Injury............. Changes in Skin Integrity Post-Acute
Care: Pressure Ulcer/Injury.
Patient Influenza Vaccine......... Percent of Residents or Patients Who
Were Assessed and Appropriately
Given the Seasonal Influenza
Vaccine (Short Stay) (NQF #0680).
Application of Falls.............. Application of Percent of Residents
Experiencing One or More Falls with
Major Injury (Long Stay) (NQF
#0674).
Application of Functional Application of Percent of Long-Term
Assessment. Care Hospital (LTCH) Patients with
an Admission and Discharge
Functional Assessment and a Care
Plan That Addresses Function (NQF
#2631).
DRR............................... Drug Regimen Review Conducted With
Follow-Up for Identified Issues--
Post Acute Care (PAC) Inpatient
Rehabilitation Facility (IRF)
Quality Reporting Program (QRP).
Change in Self-Care............... IRF Functional Outcome Measure:
Change in Self-Care Score for
Medical Rehabilitation Patients
(NQF #2633).
Change in Mobility................ IRF Functional Outcome Measure:
Change in Mobility Score for
Medical Rehabilitation Patients
(NQF #2634).
Discharge Self-Care Score......... IRF Functional Outcome Measure:
Discharge Self-Care Score for
Medical Rehabilitation Patients
(NQF #2635).
Discharge Mobility Score.......... IRF Functional Outcome Measure:
Discharge Mobility Score for
Medical Rehabilitation Patients
(NQF #2636).
------------------------------------------------------------------------
NHSN
------------------------------------------------------------------------
CAUTI............................. National Healthcare Safety Network
(NHSN) Catheter-Associated Urinary
Tract Infection Outcome Measure
(NQF #0138).
MRSA.............................. National Healthcare Safety Network
(NHSN) Facility-wide Inpatient
Hospital-onset Methicillin-
resistant Staphylococcus aureus
(MRSA) Bacteremia Outcome Measure
(NQF #1716).
CDI............................... National Healthcare Safety Network
(NHSN) Facility-wide Inpatient
Hospital-onset Clostridium
difficile Infection (CDI) Outcome
Measure (NQF #1717).
HCP Influenza Vaccine............. Influenza Vaccination Coverage among
Healthcare Personnel (NQF #0431).
------------------------------------------------------------------------
Claims-Based
------------------------------------------------------------------------
MSPB IRF.......................... Medicare Spending Per Beneficiary
(MSPB)-Post Acute Care (PAC) PAC
IRF QRP.
DTC............................... Discharge to Community--PAC IRF QRP.
PPR 30 day........................ Potentially Preventable 30-Day Post-
Discharge Readmission Measure for
IRF QRP.
PPR Within Stay................... Potentially Preventable Within Stay
Readmission Measure for IRFs.
------------------------------------------------------------------------
* The measure will be replaced with the Changes in Skin Integrity Post-
Acute Care: Pressure Ulcer/Injury measure, effective October 1, 2018.
While we did not solicit comments on currently adopted or future
IRF QRP measures, we received several comments.
Comment: Several commenters suggested additional measures that
could be removed from the IRF QRP, including the NHSN Catheter
Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138);
the NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile
Infection (CDI) Outcome Measure (NQF #1717); Influenza Vaccination
among Healthcare Personnel (NQF #0431); Application of Percent of
Residents Experiencing one or more falls with major injury; and
Application of percent of LTCH patients with an admission and discharge
functional assessment and a care plan that addresses function.
Response: We thank the commenters for their comments. We did not
propose any changes to our previously finalized measures, nor did we
propose additional measure removals from the IRF QRP. We will take
these comments into account as we engage in future measure selection
activities for the IRF QRP.
Comment: A few commenters suggested future measures for the IRF
QRP, including a measure on Pneumococcal Vaccination Coverage, an adult
immunization composite measure, and a standardized patient care survey.
Response: While we did not solicit public comment about future
measures, we will take these comments into account as we engage in
future measure development and selection activities for the IRF QRP.
E. Removal of Two IRF QRP Measures
We proposed to remove two measures from the IRF QRP measure set.
Beginning with the FY 2020 IRF QRP, we proposed to remove the National
Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset
Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome
Measure (NQF #1716). We also proposed to remove one measure beginning
with the FY 2021 IRF QRP: Percent of Residents or Patients Who Were
Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short
Stay) (NQF #0680). We discuss these proposals below.
[[Page 38559]]
1. Removal of National Healthcare Safety Network (NHSN) Facility-Wide
Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus
(MRSA) Bacteremia Outcome Measure (NQF #1716) Beginning With the FY
2020 IRF QRP
We proposed to remove the measure, Facility-wide Inpatient
Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA)
Bacteremia Outcome Measure (NQF #1716), from the IRF QRP measure set
beginning with the FY 2020 IRF QRP under measure removal Factor 8. The
costs associated with a measure outweigh the benefit of its continued
use in the IRF QRP.
We originally adopted this measure in the FY 2015 IRF PPS final
rule (79 FR 45911 through 45913). The measure assesses MRSA infections
caused by a strain of MRSA bacteria that has become resistant to
antibiotics commonly used to treat MRSA infections. The measure is
reported as a Standardized Infection Ratio (SIR) of hospital-onset
unique blood source MRSA laboratory-identified events among all
inpatients in the facility.
The data on this measure is submitted by IRFs via the National
Health Safety Network (NHSN), and we adopted it for use in several
quality reporting programs because we believe that MRSA is a serious
healthcare associated infection. To calculate a measure rate for an
individual IRF, we must be able to attribute to the IRF at least one
expected MRSA infection during the reporting period. However, we have
found that the number of IRFs with expected MRSA infections during a
given reporting period is extraordinarily low. For 99.9 percent of
IRFs, the expected MRSA infection incident rate is less than one, which
is too low to use for purposes of generating a reliable standardized
infection ratio. As a result, we are unable to calculate reliable
measure rates and publicly report those rates for almost all IRFs
because their expected infection rates during a given reporting period
are less than one. Therefore, while we still recognize that MRSA is a
serious healthcare associated infection, the benefit of this NHSN
Facility-wide Inpatient Hospital-onset MRSA Bacteremia Outcome Measure
(NQF #1716) is small. For this reason, we believe that the burden
required for data collection and submission on this measure and the
costs associated with this measure, which include the costs to maintain
and publicly report it for the IRF QRP and the costs for a small number
of IRFs to track their rates when reliable rates cannot be calculated
for most IRFs, outweigh the benefit of its continued use in the
program.
Therefore, we proposed to remove this measure from the IRF QRP,
beginning with the FY 2020 IRF QRP.
We proposed that IRFs would no longer be required to submit data on
this measure for the purposes of the IRF QRP beginning with October 1,
2018 admissions and discharges.
We invited public comment on this proposal.
Comment: Several commenters supported the proposal to remove this
measure from the IRF QRP.
Response: We thank the commenters for their support.
Final Decision: After considering public comment, we are finalizing
our proposal to remove the NHSN Facility-wide Inpatient Hospital-onset
MRSA Bacteremia Outcome Measure (NQF #1716) from the IRF QRP beginning
with the FY 2020 IRF QRP. IRFs will no longer be required to submit
data on this measure for the purposes of the IRF QRP beginning with
October 1, 2018 admissions and discharges.
2. Removal of Percent of Residents or Patients Who Were Assessed and
Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF
#0680) Beginning With the FY 2021 IRF QRP
We proposed to remove the measure, Percent of Residents or Patients
Who Were Assessed and Appropriately Given the Seasonal Influenza
Vaccine (Short Stay) (NQF #0680), from the IRF QRP beginning with the
FY 2021 IRF QRP under measure removal Factor 1. Measure performance
among IRFs is so high and unvarying that meaningful distinctions in
improvements in performance can no longer be made.
In the FY 2014 IRF PPS final rule (78 FR 47910 through 47911), we
adopted the Percent of Residents or Patients Who Were Assessed and
Appropriately Given the Seasonal Influenza Vaccine (Short Stay) measure
(NQF #0680) to assess vaccination rates among IRF patients because many
patients receiving care in the IRF setting are 65 years and older and
considered to be the target population for the influenza vaccination.
This process measure reports the percentage of stays in which the
patient was assessed and appropriately given the influenza vaccine for
the most recent influenza vaccination season. In our evaluation of this
measure, we identified that IRF performance has been high and
relatively stable, demonstrating nominal improvements across influenza
seasons since data collection began. Our analysis of this particular
measure revealed that for the 2015-2016 and the 2016-2017 influenza
seasons, nearly every IRF patient was assessed and more than 75 percent
of IRFs (n = 836) are vaccinating IRF patients who have not already
received a flu vaccination at 90 percent or higher. Further, throughout
the last two influenza seasons, the number of IRFs who achieved a
perfect score (100 percent) on this measure has grown substantially,
increasing by approximately 50 percent from 146 IRFs (12.9 percent) in
the 2015-2016 influenza season to 210 IRFs (18.8 percent) in the 2016-
2017 influenza season.
The Percent of Residents or Patients Who Were Assessed and
Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF
#0680) measure rates are also unvarying. With respect to the 2015-2016
influenza season, the mean performance score was 91.04 percent, and
with respect to the 2016-2017 influenza season, the mean performance
score on this measure was 93.88 percent. The proximity of these mean
rates to the maximum score of 100 percent suggests a potential ceiling
effect and a lack of variation that restricts distinction between
facilities. Given that performance among IRFs has remained so high and
that no meaningful distinction in performance can be made across the
majority of IRFs, we proposed the removal of this measure.
Therefore, we proposed to remove this measure from the IRF QRP
beginning with the FY 2021 IRF QRP under measure removal Factor 1.
Measure performance among IRFs is so high and unvarying that meaningful
distinctions in improvements in performance can no longer be made.
We proposed that IRFs would no longer be required to submit data on
this measure for the purposes of the IRF QRP beginning with patients
discharged on or after October 1, 2018. We also stated that we plan to
remove these data elements from the IRF-PAI version 3.0, effective
October 1, 2019, and that beginning with October 1, 2018 discharges,
IRFs should enter a dash (-) for O0250A, O0250B, and O0250C until the
IRF-PAI version 3.0 is released.
Comment: Several commenters, including MedPAC, supported the
proposal to remove the Percent of Residents or Patients Who Were
Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short
Stay) (NQF #0680) (Patient Influenza Vaccine) measure from the IRF QRP.
Several commenters stated that the removal of this measure will allow
providers to
[[Page 38560]]
devote more time to patient care by reducing the burden of collecting
and reporting data. A few commenters, including MedPAC, suggested
focusing on more meaningful measures, as this measure is no longer
effective in improving the quality of care or patient outcomes. A few
commenters requested that CMS provide guidance to clarify the
appropriateness of dash use for the IRF-PAI influenza vaccine items
beginning FY 2019.
Response: We appreciate the support from MedPAC and other
commenters for the proposed removal of the Patient Influenza Vaccine
measure from the IRF QRP. Due to IRFs effectively assessing and
vaccinating patients across the 2015-2016 and 2016-2017 influenza
seasons, performance on this measure has remained so high that we are
no longer able to make meaningful distinctions in improvements in
performance. Removing the Patient Influenza Vaccine measure due to its
high and unvarying performance will allow providers to address highest
priority issues for improving overall health and focus more on
meaningful measures that are most vital to patient outcomes in the IRF
setting. We will provide ongoing guidance to IRFs to clarify that use
of a dash for IRF-PAI items O0250A, O0250B, and O0250C beginning FY
2019 is appropriate and will not cause a non-compliance determination.
Comment: Some commenters did not support the removal of the Patient
Influenza Vaccine measure from the IRF QRP, citing concerns with
patient care consequences that could occur as a result of its removal.
One commenter stated that the Patient Influenza Vaccine measure is an
important safety measure that may be overlooked if providers are no
longer required to report data. Another commenter indicated that
removing the measure will send the impression that preventative health
services, such as immunizations, are not a priority in the inpatient
setting, could leave a vulnerable population of Medicare-beneficiaries
more susceptible to vaccine-preventable illness, and may generate
reporting confusion among providers.
Response: While we understand that assessing and appropriately
vaccinating patients are important components of the care process, many
patients admitted to IRFs come from an acute care setting where
influenza vaccinations are tracked and, due to that tracking, have
already been immunized before they are admitted to the IRF. For that
reason, the process of assessing IRF patients for influenza vaccination
is duplicative of a process that most of these patients have already
undergone. In addition, our analysis has shown that IRFs regularly
assess and vaccinate their patients when appropriate to do so. As a
result, we do not believe that the removal of the measure from the IRF
QRP will lead to lower immunization rates in the IRF patient
population.
Final decision: After careful consideration of the public comments,
we are finalizing our proposal to remove the Percent of Residents or
Patients Who Were Assessed and Appropriately Given the Seasonal
Influenza Vaccine (Short Stay) (NQF #0680) measure from the IRF QRP
beginning with the FY 2021 IRF QRP. IRFs will no longer be required to
submit data on this measure for the purposes of the IRF QRP beginning
with patients discharged on or after October 1, 2018. We plan to remove
these data elements from the IRF-PAI version 3.0, effective October 1,
2019. Beginning with October 1, 2018 discharges, IRFs should enter a
dash (-) for O0250A, O0250B, and O0250C until the IRF-PAI version 3.0
is released.
F. IMPACT Act Implementation Update
In the FY 2018 IRF PPS final rule (82 FR 36285 through 36286), we
stated that we intended to specify two measures that would satisfy the
domain of accurately communicating the existence and provision of the
transfer of health information and care preferences under section
1899B(c)(1)(E) of the Act no later than October 1, 2018, and intended
to propose to adopt them for the FY 2021 IRF QRP with data collection
beginning on or about October 1, 2019.
In the FY 2019 IRF PPS proposed rule (83 FR 21002 through 21003),
we stated that, as a result of the input provided during a public
comment period between November 10, 2016 and December 11, 2016, input
provided by a technical expert panel (TEP), and pilot measure testing
conducted in 2017, we are engaging in continued development work on
these two measures, including supplementary measure testing and
providing the public with an opportunity for comment in 2018. We stated
that we would reconvene a TEP for these measures in mid-2018, which
occurred in April 2018. We stated that we now intend to specify the
measures under section 1899B(c)(1)(E) of the Act no later than October
1, 2019, and intend to propose to adopt the measures for the FY 2022
IRF QRP, with data collection beginning with patients discharged on or
after October 1, 2020. For more information on the pilot testing, we
refer readers to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
Comment: A few commenters supported the updated implementation
timeline for the transfer of health information and care preference
domain measures, allowing additional time for measure development. A
commenter further stated that, given the complexity of the draft
measures under development for this domain, it is important that CMS
prioritize sound measure development to ensure that the measures are
implementable, minimally burdensome to providers, and add value beyond
current care practices.
Response: We appreciate the commenters' support.
Comment: A few commenters noted the extension of the IMPACT Act
measure deadline for the transfer of health information and care
preferences domain measures and requested further explanation and
clarification for extending quality measure implementation beyond
statutory deadlines. Another commenter questions why the agency is
delaying these measures, but did not delay the implementation of other
measures, such as the Section GG functional assessment items and
measures despite multiple requests from stakeholders to delay
implementation to facilitate more deliberation, input, and research.
Response: In the FY 2016 proposed and final rules, we described the
statutory timeline for measure specification under the IMPACT Act and
how that timeline was not feasible in light of operational and other
practical constraints. We outlined our historical timeline for
developing and adopting quality measures, which pre-dates the IMPACT
Act, and how that timeline takes into consideration the time needed to
specify and adopt valid and reliable measures, as well as give IRFs
enough notice of their new data reporting obligations. We intended to
specify the measures required by the IMPACT Act in accordance with our
historical timeline in order to ensure that the measures we adopt are
developed in a transparent manner that involves stakeholder input, MAP
review, and NQF endorsement.
We have largely been able to comply with the implementation
timeline we set forth in the FY 2016 proposed and final rules. The
measures we have adopted in accordance with that timeline were
developed in a transparent manner and incorporate both expert and
stakeholder input. They were also reviewed by the MAP and, in many
cases, are NQF-endorsed for at least one of the four PAC settings. We
[[Page 38561]]
also considered the input of stakeholders who requested that we conduct
further testing and research before we adopted various measures and
determined, based on our own assessment of the evidence, as well as
input of experts and other stakeholders, that the measures were valid
and reliable enough to be adopted.
The two measures that would satisfy the domain of accurately
communicating the existence and provision of the transfer of health
information and care preferences that are currently under development
do not enjoy a level of support that is akin to the support that we
received for other IMPACT Act measures. Results from the pilot test of
the original measure concept recommended CMS to continue to further
modify the measures to increase the usefulness and feasibility of the
constructs for PAC settings. The core concern of the MAP was the
measure testing, including incomplete development, and other topics
such as what information would be needed at the time of transfer and
measure attribution issues. Based on input from the MAP and more
recently from stakeholders and our own research, we have determined
that the measures are not sufficiently developed at this time to
support their use in the four PAC settings, and we have concluded that
it is better to delay their implementation while we engage in further
development and testing than it would be to adopt the measures
prematurely.
G. Form, Manner, and Timing of Data Submission Under the IRF QRP
Under our current policy, IRFs report data on IRF QRP assessment-
based measures and standardized patient assessment data by completing
applicable sections of the IRF-PAI and submitting the IRF-PAI to CMS
through the Quality Improvement Evaluation System (QIES) Assessment
Submission and Processing (ASAP) system. For more information on IRF
QRP reporting through the Quality Improvement and Evaluation System
Assessment Submission and Processing (QIES ASAP) system, refer to the
``Related Links'' section at the bottom of https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Software.html. Data on IRF QRP measures that are also collected by the
Centers for Disease Control and Prevention (CDC) for other purposes are
reported by IRFs to the CDC through the NHSN, and the CDC then
transmits the relevant data to CMS. Information regarding the CDC's
NHSN is available at https://www.cdc.gov/nhsn/index.html. We refer
readers to the FY 2018 IRF PPS final rule (82 FR 36291 through 36292)
for the data collection and submission timeframes that we finalized for
the IRF QRP.
We previously codified at Sec. 412.634(b)(1) of our regulations
the requirement that IRFs submit data on measures specified under
sections 1886(j)(7)(D), 1899B(c)(1), and 1899B(d)(1) of the Act in the
form and manner, and at a time, specified by CMS. In the FY 2019 IRF
PPS proposed rule (83 FR 21003), we proposed to revise Sec.
412.634(b)(1) to include the policy we previously finalized in the FY
2018 IRF PPS final rule (82 FR 36292 through 36293) that IRFs must also
submit standardized patient assessment data required under section
1899B(b)(1) of the Act in the form and manner, and at a time, specified
by CMS.
We invited public comment on this proposal.
Comment: One commenter supported the codification of the policy
that IRFs must also submit standardized patient assessment data
required under section 1899B(b)(1) of the Act in the form and manner,
and at a time, specified by CMS.
Response: We appreciate the commenter's support for this proposal.
Comment: Several commenters expressed concern about data submission
using the National Healthcare Safety Network (NHSN), including the
additional time and effort required to submit data using this method.
Response: We acknowledge the commenters' concerns, but note that we
did not propose changes to the data submission requirements related to
the NHSN. We refer readers to the IRF NHSN website for IRFs, https://www.cdc.gov/nhsn/inpatient-rehab/index.html, which contains guidelines
and protocols for NHSN submission, along with Frequently Asked
Questions and resources for data submission.
Final decision: After careful consideration of the public comments,
we are finalizing our proposal to revise Sec. 412.634(b)(1) and codify
in our regulations that IRFs must also submit standardized patient
assessment data required under section 1899B(b)(1) of the Act in the
form and manner, and at a time, specified by CMS.
H. Changes to Reconsideration Requirements Under the IRF QRP
Section 412.634(d)(1) of our regulations states, in part, that IRFs
found to be non-compliant with the quality reporting requirements for a
particular fiscal year will receive a letter of non-compliance through
the Quality Improvement and Evaluation System Assessment Submission and
Processing (QIES-ASAP) system, as well as through the United States
Postal Service.
In the FY 2019 IRF PPS proposed rule (83 FR 21003), we proposed to
revise Sec. 412.634(d)(1) to expand the methods by which we would
notify an IRF of non-compliance with the IRF QRP requirements for a
program year. Revised Sec. 412.634(d)(1) would state that we would
notify IRFs of non-compliance with the IRF QRP requirements via a
letter sent through at least one of the following notification methods:
The QIES-ASAP system, the United States Postal Service, or via an email
from the Medicare Administrative Contractor (MAC). We believe that this
change will address feedback from providers who requested additional
methods for notification.
We also proposed to revise Sec. 412.634(d)(5) to clarify that we
will notify IRFs, in writing, of our final decision regarding any
reconsideration request using the same notification process.
We invited public comments on these proposals.
Comment: One commenter was supportive of our proposal to use the
same process to notify IRFs of both non-compliance and our final
decision on reconsideration requests.
Response: We appreciate the commenter's support.
Comment: Many commenters supported the efforts by CMS to provide
more methods of communication for notifying IRFs of IRF QRP non-
compliance and reconsideration decisions. A few commenters requested
additional details about the logistics of these methods of
notification, and a few had concerns that this would add uncertainty to
the notification process. Some providers expressed confusion about how
many methods of notification would be required. One commenter requested
a timeline for this change. Some commenters questioned who in the
provider organization would receive the notification or wanted the
option to designate one person.
Response: We thank commenters for their support. We will use at
least one method of notification, and providers will be notified
regarding the specific method of communication that we will use via the
IRF QRP Reconsideration and Exception & Extension website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Reporting-Reconsideration-and-Exception-and-Extension.html and announcements via
the PAC listserv. The announcements will be posted annually following
the May 15 data
[[Page 38562]]
submission deadline--prior to the distribution of the initial notices
of non-compliance determination in late spring/early summer. Messaging
will include method of communication for the notices, instructions for
sending a reconsideration request, and the final deadline for
submitting the request. This policy would be effective October 1, 2018.
With regard to the point of contact for a specific facility, our
notifications are sent to the point of contact on file in the QIES
database. This information is populated via ASPEN. It is the
responsibility of the facility to ensure that this information is up-
to-date. For information regarding how to update provider information
in QIES, we refer providers to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/How-to-Update-IRF-Demographic-Data-1-4-18-Final.pdf.
Comment: A few commenters did not support the use of MACs in the
notification process, citing concerns that this might cause additional
confusion. One commenter noted that MACs do not have prior experience
with the IRF QRP, and are too bureaucratically complex for efficient
provider communication. Several commenters suggested utilizing the
existing QRP Helpdesk contractor to communicate QRP non-compliance.
Response: The MACs have been active in the notification process
since the establishment of the IRF QRP. MACs serve as the primary
operational contact between the Medicare FFS program and IRFs, and they
work with CMS and the agency's other contractors to implement the 2
percent reduction in the annual increase factor within the Fiscal
Intermediary Standard System (FISS). They also send to IRFs both the
initial notices of non-compliance with the requirements of the IRF QRP
and the final decisions on reconsideration requests. We are confident
that the MACs will continue to be a valuable addition to the
notification process.
Final decision: After careful consideration of the public comments,
we are finalizing our proposal to revise Sec. 412.634(d)(1) to state
that we will notify IRFs of non-compliance with the IRF QRP
requirements via a letter sent through at least one of the following
notification methods: The QIES-ASAP system, the United States Postal
Service, or via an email from the Medicare Administrative Contractor
(MAC). We are also finalizing our proposal to revise Sec.
412.634(d)(5) to clarify that we will notify IRFs, in writing, of our
final decision regarding any reconsideration request using the same
notification process.
I. Policies Regarding Public Display of Measure Data for the IRF QRP
Section 1886(j)(7)(E) of the Act requires the Secretary to
establish procedures for making the IRF QRP data available to the
public after ensuring that an IRF has the opportunity to review its
data prior to public display. Measure data are currently displayed on
the IRF Compare website, an interactive web tool that assists
individuals by providing information on IRF quality of care to those
who need to select an IRF. For more information on IRF Compare, we
refer readers to https://www.medicare.gov/inpatientrehabilitationfacilitycompare/.
In the FY 2019 IRF PPS proposed rule (83 FR 21003), we proposed to
begin publicly displaying data on the following four assessment-based
measures in CY 2020, or as soon thereafter as technically feasible: (1)
Change in Self-Care (NQF #2633); (2) Change in Mobility (NQF #2634);
(3) Discharge Self-Care Score (NQF #2635); (4) and Discharge Mobility
Score (NQF #2636). Data collection for these four assessment-based
measures began with patients discharged on or after October 1, 2016. We
proposed to display data for these assessment-based measures based on
four rolling quarters of data, initially using discharges from January
1, 2019 through December 31, 2019 (Quarter 1 2019 through Quarter 4
2019). To ensure the statistical reliability of the data for these four
assessment-based measures, we also proposed that if an IRF has fewer
than 20 cases during any four consecutive rolling quarters of data that
we are displaying for any of these measures, then we would note in our
public display of that measure that with respect to that IRF the number
of cases/patient stays is too small to publicly report.
We sought public comment on these proposals.
Comment: One commenter supported the proposal to begin publicly
displaying the four assessment-based measures on the IRF Compare
website in CY 2020.
Response: We appreciate the commenter's support.
Comment: A few commenters recommended that CMS provide education
for IRFs prior to the public display of the four assessment-based
measures. The commenters requested training for providers on the
calculation and interpretation of their performance data in the CASPER
reports to ensure accurate public reporting. Some commenters also
requested increased transparency regarding the statistical
methodologies that CMS uses to calculate provider performance.
Response: We recently held provider training in May 2018 on the
interpretation of the assessment-based quality measure data on the
CASPER reports as well as the data review process prior to public
reporting. These and other training materials are posted on the IRF QRP
website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/index.html. We intend to
hold additional training programs on this topic and will include
information on the calculation of the performance data including for
the four assessment-based measures: (1) Change in Self-Care (NQF
#2633); (2) Change in Mobility (NQF #2634); (3) Discharge Self-Care
Score (NQF #2635); (4) and Discharge Mobility Score (NQF #2636).
Information related to measure calculation is currently available in
IRF QM User's Manual, available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Reporting-Program-Measures-Information-.html. We
will continue to closely monitor the performance data and assist IRFs
on CASPER and public reporting efforts through ongoing stakeholder
education, national trainings, IRF provider announcements, website
postings, CMS Open Door Forums, and responses to help desk inquiries.
Comment: Some commenters provided recommendations on the public
display of the assessment-based measures. One commenter suggested
revising the measure names to better distinguish the measures and that
CMS provide an explanation of the differences between these assessment-
based measures in different post-acute care settings. This commenter
further recommended that the data displayed on the IRF Compare website
be stratified by clinical conditions to make the data more valuable for
patients and their caregivers. Another commenter suggested that the
assessment-based measures be divided into two larger categories labeled
``Self-Care'' and ``Mobility'' for further clarity, and recommended
that the observed, expected, and national values be publicly displayed
on the IRF Compare website.
Response: We appreciate commenters' suggestions on the public
display of the assessment-based measures on the IRF Compare website,
and we will take these suggestions into consideration. We would like to
clarify that the measure names that will be displayed on the IRF
Compare website will use consumer-
[[Page 38563]]
friendly language that differs from the technical measure name. A
crosswalk between the consumer-friendly name and the technical measure
name is available on the IRF Compare website at https://www.medicare.gov/inpatientrehabilitationfacilitycompare/#about/theData.
Comment: MedPAC expressed concern about the functional status and
other quality measure data that would be publicly displayed on the IRF
Compare website. MedPAC cautioned that because functional status data
are gathered through patient observation, there are concerns regarding
the objectivity of this data and encouraged CMS to monitor the accuracy
of the data and to confirm the inter-rater reliability of the four
assessment-based measures to be displayed on the IRF Compare website.
Response: We thank MedPAC for its feedback regarding the public
display of the four assessment-based measures. We understand these
concerns and will continue to monitor the reliability and validity of
all IRF QRP measures, including these measures, by conducting training
on how to properly collect and report the measure data, and conducting
our own testing as part of our measure monitoring activities.
Comment: Some commenters opposed the public display of the four
assessment-based measures on the IRF Compare website in CY 2020. One
commenter requested that CMS defer, or suspend, the public display of
the assessment-based measures that we proposed to publicly report until
providers have been given the opportunity to review the risk adjustment
model and evaluate their performance. Other commenters said they do not
support the proposal without first receiving more information on the
way these measures will be publicly displayed.
A few commenters requested that CMS provide additional information
on providers' CASPER reports. Another commenter was concerned that risk
adjusted data are not currently available on the CASPER reports, and
therefore, IRFs do not have sufficient information to track their
performance and ensure that their provider-level performance is
accurately represented on IRF Compare. One commenter suggested that CMS
provide actionable patient-level data for these measures in the
providers' CASPER reports.
Response: We plan to provide IRFs with the intercept and
coefficient values needed for risk-adjustment in the fall of 2018. We
also plan to include data on the four assessment-based measures,
including patient-level data and risk-adjusted data, in the CASPER
reports that we provide to IRFs in the fall of 2018, and training to
assist IRFs in interpreting those data and how the data will be
publicly reported. We believe that this information will allow IRFs to
track their performance and ensure that their performance is accurately
represented on IRF Compare. Details about the risk adjustment model
variables and the calculation of these assessment-based measures can
currently be found in the IRF QM User's Manual, available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Reporting-Program-Measures-Information-.html.
Comment: One commenter stated that there is currently no
standardization of the beneficiary populations across IMPACT Act
measures and recommended that CMS align these patient populations
across PAC settings. If this cannot be done, the commenter then
suggested using a uniform population, such as on Medicare Part A
patients, for the purposes of public reporting for cross-setting
comparisons. The commenter further recommended that in the future the
data should be stratified by payer status, and that CMS should work
with stakeholders to develop appropriate reporting methods for non-
Medicare patients. Another commenter expressed concern about the
standardization of Section GG functional status data and related
measures across PAC settings and about the accurate depiction of
differences between settings viewed on public websites.
Response: We thank the commenters for their comments. We would like
to note that as we continue to develop and refine all quality measures
for purposes of assessment and public reporting, we are working to
align Medicare patient populations across the PAC settings. We will
take into consideration the suggestion to use a uniform patient
population for purposes of reporting cross-setting comparisons. We will
ensure that all future development work will be aided by public comment
and work with our stakeholders.
Comment: We received comments on a number of other issues related
to public display. One commenter recommended implementing consumer
testing prior to public reporting. A few commenters recommended that
CMS provide patient-level feedback data for their claims-based measures
to help IRFs improve their quality of care. One commenter requested
that CMS evaluate the use of performance categories on the IRF Compare
website and either remove the current performance categories or use a
different methodology.
Response: We thank commenters for their comments. We will consider
the commenters' suggestions about consumer testing and the use of
performance categories, and we will provide the details prior to
publicly reporting the four assessment-based measures. We did not
propose any changes related to the public display of claims-based or
CDC NHSN measures, which currently include performance categories, or
to provide patient-level feedback data for their claims-based measures.
However, we appreciate the feedback and will consider the commenters'
concerns as we continue to monitor and evaluate measure performance and
reporting methods.
Final decision: After consideration of the public comments, we are
finalizing our proposal to begin publicly displaying data on the
following four assessment-based measures in CY 2020, or as soon
thereafter as technically feasible: (1) Change in Self-Care (NQF
#2633); (2) Change in Mobility (NQF #2634); (3) Discharge Self-Care
Score (NQF #2635); (4) and Discharge Mobility Score (NQF #2636) based
on four rolling quarters of data, initially using discharges from
January 1, 2019 through December 31, 2019 (Quarter 1 2019 through
Quarter 4 2019).
J. Method for Applying the Reduction to the FY 2019 IRF Increase Factor
for IRFs That Fail To Meet the Quality Reporting Requirements
As previously noted, section 1886(j)(7)(A)(i) of the Act requires
the application of a 2-percentage point reduction of the applicable
market basket increase factor for payments for discharges occurring
during such fiscal year for IRFs that fail to comply with the quality
data submission requirements. We proposed to apply a 2-percentage point
reduction to the applicable FY 2019 market basket increase factor in
calculating an adjusted FY 2019 standard payment conversion factor to
apply to payments for only those IRFs that failed to comply with the
data submission requirements. As previously noted, application of the
2-percentage point reduction may result in an update that is less than
0.0 for a fiscal year and in payment rates for a fiscal year being less
than such payment rates for the preceding fiscal year. Also, reporting-
based reductions to the market basket increase factor will not be
cumulative; they will only apply for the FY involved.
We invited public comment on the proposed method for applying the
reduction to the FY 2019 IRF increase
[[Page 38564]]
factor for IRFs that fail to meet the quality reporting requirements.
Comment: Some commenters suggested that CMS provide flexibility in
its application of the IRF QRP payment penalty for IRFs who make a
good-faith effort to comply and submit quality reporting data.
Response: We interpret the commenter's suggestion that CMS take
into consideration case by case exceptions and apply leniency for
providers have attempted but failed to submit their quality reporting
data for the IRF QRP. While we did not seek comment on flexibilities on
which the penalty is applied, we note that we have provided flexibility
where the failure of the IRF to comply with the requirements of the IRF
QRP stemmed from circumstances beyond its control. For example, we have
finalized policies that grant exceptions or extensions for IRFs if we
determine that a systemic problem with one of our data collection
systems affected the ability of IRFs to submit data (79 FR 45920). We
have also adopted policies (78 FR 47920) that allow us to grant
exemptions or extensions to an IRF if it has experienced an
extraordinary circumstance beyond its control. In addition we set the
reporting compliance threshold at 95 percent rather than at 100 percent
to data to for account for the rare instances when assessment data
collection and submission maybe impossible, such as when patients have
been discharged emergently, or against medical advice.
Table 12 shows the calculation of the adjusted FY 2019 standard
payment conversion factor that will be used to compute IRF PPS payment
rates for any IRF that failed to meet the quality reporting
requirements for the applicable reporting period.
Table 12--Calculations To Determine the Adjusted FY 2019 Standard
Payment Conversion Factor for IRFs That Failed To Meet the Quality
Reporting Requirement
------------------------------------------------------------------------
Explanation for adjustment Calculations
------------------------------------------------------------------------
Standard Payment Conversion Factor for FY 2018.......... $15,838
Market Basket Increase Factor for FY 2019 (2.9 percent), x 0.9935
reduced by 0.8 percentage point for the productivity
adjustment as required by section 1886(j)(3)(C)(ii)(I)
of the Act, reduced by 0.75 percentage point in
accordance with sections 1886(j)(3)(C) and (D) of the
Act and further reduced by 2 percentage points for IRFs
that failed to meet the quality reporting requirement..
Budget Neutrality Factor for the Wage Index and Labor- x 1.0000
Related Share..........................................
Budget Neutrality Factor for the Revisions to the CMG x 0.9981
Relative Weights.......................................
---------------
Adjusted FY 2019 Standard Payment Conversion Factor. = $15,705
------------------------------------------------------------------------
Our regulations currently address the 2 percentage point payment
reduction for failure to meet requirements under the IRF QRP in two
places: Sec. Sec. 412.624(c)(4) and 412.634(b)(2). We believe that
these provisions are duplicative and proposed to revise the regulations
so that the payment reduction is addressed only in Sec. 412.624(c)(4).
As noted in section X.C. of this final rule, we are finalizing our
proposal to remove the language regarding the payment reduction that is
currently at Sec. 412.634(b)(2) and to codify that section instead the
retention and removal policies for the IRF QRP.
We also proposed to revise Sec. 412.624(c)(4)(i) to clarify that
an IRF's failure to submit data under the IRF QRP in accordance with
Sec. 412.634 will result in the 2 percentage point reduction to the
applicable increase factor specified in Sec. 412.624(a)(3).
Finally, we proposed to revise Sec. 412.624(c)(4) for greater
consistency with the language of section 1886(j)(7)(A)(i) of the Act.
Specifically, we would revise paragraph (i) to clarify that the 2
percentage point reduction is applied ``after application of
subparagraphs (C)(iii) and (D) of section 1886(j)(3) of the Act.'' In
addition, we would add a new paragraph (iii) that clarifies that the 2
percentage point reduction required under section 1886(j)(7)(A)(i) of
the Act may result in an update that is less than 0.0 for a fiscal
year. We sought public comment on these proposals.
We did not receive any public comments on the revision of the
regulatory text at Sec. 412.624(c).
Final decision: We are finalizing our proposed revisions to our
regulatory text at Sec. 412.624(c).
XI. Miscellaneous Comments
We received several comments that were outside the scope of the FY
2019 IRF PPS proposed rule. Specifically, we received comments
regarding the processes for updating the IRF facility-level adjustment
factors and the transparency of these updates, transitions for IRFs
that are redesignated from rural to urban status due to CBSA updates,
the IRF 60 percent rule and ICD-10-CM codes that might be appropriate
for addition to the presumptive methodology, coverage of recreational
therapy under the IRF PPS, participation of licensed therapy assistants
in the interdisciplinary team meetings, requirements for hospitals to
publicly report charges on the internet, access to IRF services for
beneficiaries in Medicare Advantage plans, hospital-within-hospital
requirements for satellite facilities, MedPAC recommendations regarding
monitoring of inter-rater reliability concerns with the IRF-PAI, the
role of residents in completing IRF documentation requirements, need
for the overall plan of care, and the overall need to update rules on
an ongoing basis to maintain their relevancy. We thank commenters for
bringing these issues to our attention, and we will take these comments
into consideration for potential policy refinements.
XII. Provisions of the Final Regulations
In this final rule, we are adopting the provisions set forth in the
FY 2019 IRF PPS proposed rule (83 FR 20972). Specifically:
We will update the FY 2019 IRF PPS relative weights and
average length of stay values using the most current and complete
Medicare claims and cost report data in a budget-neutral manner, as
discussed in section IV. of this final rule.
The facility-level adjustments will remain frozen at FY
2014 levels for FY 2015 and all subsequent years, as discussed in
section V. of this final rule.
We will update the FY 2019 IRF PPS payment rates by the
market basket increase factor, based upon the most current data
available, with a 0.75 percentage point reduction as required by
sections 1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(v) of the Act and a
productivity adjustment required by section 1886(j)(3)(C)(ii)(I) of the
Act, as described in section VI. of this final rule.
We will update the FY 2019 IRF PPS payment rates by the FY
2019 wage index and the labor-related share in a
[[Page 38565]]
budget-neutral manner, as discussed in section VI. of this final rule.
We will calculate the final IRF standard payment
conversion factor for FY 2019, as discussed in section VI. of this
final rule.
We will update the outlier threshold amount for FY 2019,
as discussed in section VII. of this final rule.
We will update the CCR ceiling and urban/rural average
CCRs for FY 2019, as discussed in section VII. of this final rule.
We will remove the FIM\TM\ Instrument and Associated
Function Modifiers from the IRF-PAI beginning with FY 2020 and make
refinements to the case-mix classification system using 2 full years of
data, beginning with FY 2020, as discussed in section VIII. of this
final rule.
We will revise certain IRF coverage requirements beginning
with FY 2019, as discussed in section IX. of this final rule.
We will adopt updates to the IRF QRP in accordance with
sections 1886(j)(7) of the Act, as discussed in section X. of this
final rule.
XIII. Request for Information on Promoting Interoperability and
Electronic Healthcare Information Exchange Through Possible Revisions
to the CMS Patient Health and Safety Requirements for Hospitals and
Other Medicare- and Medicaid-Participating Providers and Suppliers
In the FY 2019 IRF PPS proposed rule, we included a Request for
Information (RFI) related to promoting interoperability and electronic
healthcare information exchange (83 FR 20972 through 21015). We
received 15 comments on this RFI, and appreciate the input provided by
commenters.
XIV. Collection of Information Requirements
A. Statutory Requirement for Solicitation of Comments
Under the Paperwork Reduction Act of 1995 (PRA), we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the OMB for review and approval. To fairly evaluate whether an
information collection should be approved by OMB, section 3506(c)(2)(A)
of the PRA requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency;
The accuracy of our estimate of the information collection
burden;
The quality, utility, and clarity of the information to be
collected; and
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
This final rule makes reference to associated information
collections that are not discussed in the regulation text contained in
this document.
B. Collection of Information Requirements for Updates Related to the
IRF PPS
As discussed in section VIII.A of this final rule, we are removing
the FIM\TM\ instrument and associated Function Modifiers from the IRF-
PAI beginning with FY 2020, that is, for all IRF discharges beginning
on or after October 1, 2019. The removal of the FIM\TM\ instrument and
associated Function Modifiers from the IRF-PAI would result in the
removal of 11 data items. As a result, we estimate the burden and costs
associated with the collection of this data will be reduced for IRFs.
Specifically, we estimate the removal of the FIM\TM\ instrument and the
associated Function Modifiers will save 25 minutes of nursing/clinical
staff time used to report data on both admission and discharge which
was the estimated time needed to complete these items when the FIMM\TM\
instrument was added to the IRF-PAI in the FY 2002 IRF PPS Final Rule
(66 FR 41375). We believe that the FIM\TM\ items we are removing may be
completed by social service assistants, Licensed Practical Nurses
(LPN), recreational therapists, social workers, dietitians and
nutritionists, Registered Nurses (RN), Occupational Therapists (OT),
Speech Language Pathologists (SLP) and audiologists, and or Physical
Therapists (PT), depending on the item. To estimate the burden
associated with the collection of these data items, we obtained mean
hourly wages for these staff from the U.S. Bureau of Labor Statistics'
May 2017 National Occupational Employment and Wage Estimates (https://www.bls.gov/oes/current/oes_nat.htm) and doubled them to account for
overhead and fringe benefits. We estimate IRF-PAI preparation and
coding costs using a social worker hourly wage rate of $49.64, a social
work assistant's hourly wage rate of $34.10, an RN hourly wage rate of
$70.72, an LPN hourly wage rate of $43.96, a recreation therapist
hourly wage rate of $47.76, a dietitian/nutritionist hourly wage rate
of $57.84, a speech-language pathologist hourly wage rate of $76.70, an
audiologist hourly wage rate of $76.96, an occupational therapist
hourly wage rate of $81.38, and a physical therapist hourly wage rate
of $84.68. Using the mean hourly wages (doubled to account for overhead
and fringe benefits) for the staffing categories above, we calculate an
average rate of $62.37. The $62.37 rate is a blend of all of these
categories, and reflects the fact that IRF providers have historically
used all of these clinicians for preparation and coding for the IRF-
PAI.
To estimate the burden reduction associated with this change, we
estimate that there are approximately 403,341 discharges from 1,126
IRFs in FY 2017 resulting in an approximate average of 358 discharges
per IRF annually. This equates to a reduction of 168,059 hours for all
IRFs (403,341 discharges x 0.416 hours). This is 149 hours (168,059
hours/1,126 IRFs) per IRF annually. We estimate the total cost savings
per IRF will be approximately $9,293 (149 hours x $62.37) annually. We
estimate that the total cost savings for all IRF providers will be
approximately $10.5 million (1,126 IRFs x $9,293) annually.
C. Collection of Information Requirements for Updates Related to the
IRF QRP
An IRF that does not meet the requirements of the IRF QRP for a
fiscal year will receive a 2 percentage point reduction to its
otherwise applicable annual increase factor for that fiscal year.
Information is not currently available to determine the precise number
of IRFs that will receive less than the full annual increase factor for
FY 2019 due to non-compliance with the requirements of the IRF QRP.
We believe that the burden associated with the IRF QRP is the time
and effort associated with complying with the requirements of the IRF
QRP. As of June 1, 2018, there are approximately 1,126 IRFs reporting
quality data to CMS. For the purposes of calculating the costs
associated with the collection of information requirements, we obtained
mean hourly wages for these staff from the U.S. Bureau of Labor
Statistics' May 2017 National Occupational Employment and Wage
Estimates (http://www.bls.gov/oes/current/oes_nat.htm). To account for
overhead and fringe benefits, we have doubled the hourly wage. These
amounts are detailed in Table 13.
[[Page 38566]]
Table 13--U.S. Bureau of Labor Statistics' May 2017 National Occupational Employment and Wage Estimates
----------------------------------------------------------------------------------------------------------------
Overhead and Adjusted
Occupation title Occupation Mean hourly fringe benefit hourly wage ($/
code wage ($/hr) ($/hr) hr)
----------------------------------------------------------------------------------------------------------------
Registered Nurse (RN)........................... 29-1141 $35.65 $35.65 $71.30
Medical Records and Health Information 29-2071 18.83 18.83 37.66
Technician.....................................
----------------------------------------------------------------------------------------------------------------
As discussed in section X.4. of this rule, we are finalizing our
proposal to remove two measures from the IRF QRP.
In section X.4.2 of the final rule, we are finalizing our proposal
to remove the measure, Percent of Residents or Patients Who Were
Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short
Stay) (NQF #0680), beginning with the FY 2021 IRF QRP. IRFs will no
longer be required to submit data on this measure beginning with
patients discharged on October 1, 2018, and the items will be removed
from the IRF-PAI V3.0, effective October 1, 2019. As a result, the
estimated burden and cost for IRFs for complying with requirements of
the FY 2021 IRF QRP will be reduced. Specifically, we believe that
there will be a 4.8 minute reduction in clinical staff time to report
data per patient stay. We estimate 403,341 discharges from 1,126 IRFs
annually. This equates to a decrease of 32,267 hours in burden for all
IRFs (0.08 hours per assessment x 403,341 discharges). Given 4.8
minutes of RN time at $71.30 per hour completing an average of 358 sets
of IRF-PAI assessments per provider per year, we estimate that the
total cost will be reduced by $2,043 per IRF annually, or $2,300,657
for all IRFs annually. This decrease in burden will be accounted for in
the information collection under OMB control number (0938-0842).
In addition, we are finalizing our proposal to remove one CDC
National Healthcare Safety Network (NHSN) measure, beginning with the
FY 2020 IRF QRP, which will result in a decrease in burden and cost for
IRFs. Providers will no longer be required to submit data beginning
with October 1, 2018 admissions and discharges. We estimate that the
removal of the National Healthcare Safety Network (NHSN) Facility-wide
Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus
(MRSA) Bacteremia Outcome Measure (NQF #1716) will result in a 3-hour
(15 minutes per MRSA submission x 12 estimated submissions IRF per
year) reduction in clinical staff time annually to report data which
equates to a decrease of 3,378 hours (3 hours burden per IRF per year x
1,126 total IRFs) in burden for all IRFs. Given 10 minutes of RN time
at $71.30 per hour, and 5 minutes of Medical Records or Health
Information Technician at $37.66 per hour, for the submission of 12
estimated submissions of MRSA data to the NHSN per IRF per year, we
estimate that the total cost of complying with requirements of the IRF
QRP will be reduced by $180 per IRF annually, or $202,973 for all IRFs
annually.
In summary, the finalized IRF QRP measure removals will result in a
burden reduction of $2,223 per IRF annually, and $2,503,630 for all
IRFs annually.
XV. Regulatory Impact Analysis
A. Statement of Need
This final rule updates the IRF prospective payment rates for FY
2019 as required under section 1886(j)(3)(C) of the Act. It responds to
section 1886(j)(5) of the Act, which requires the Secretary to publish
in the Federal Register on or before the August 1 that precedes the
start of each fiscal year, the classification and weighting factors for
the IRF PPS's case-mix groups, and a description of the methodology and
data used in computing the prospective payment rates for that fiscal
year.
This final rule also implements sections 1886(j)(3)(C) and (D) of
the Act. Section 1886(j)(3)(C)(ii)(I) of the Act requires the Secretary
to apply a multifactor productivity adjustment to the market basket
increase factor, and to apply other adjustments as defined by the Act.
The productivity adjustment applies to FYs from 2012 forward. The other
adjustments apply to FYs 2010 through 2019.
Furthermore, this final rule also adopts policy changes under the
statutory discretion afforded to the Secretary under section 1886(j)(7)
of the Act. Specifically, we are removing the FIM\TM\ instrument and
associated Function Modifiers from the IRF-PAI, revising certain IRF
coverage requirements, removing two measures from the IRF QRP measure
set, and codifying policies that were previously finalized under the
IRF QRP.
B. Overall Impact
We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Act, section 202 of the
Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. L. 104-4),
Executive Order 13132 on Federalism (August 4, 1999), the Congressional
Review Act (5 U.S.C. 804(2) and Executive Order 13771 on Reducing
Regulation and Controlling Regulatory Costs (January 30, 2017).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). Section
3(f) of Executive Order 12866 defines a ``significant regulatory
action'' as an action that is likely to result in a rule: (1) Having an
annual effect on the economy of $100 million or more in any 1 year, or
adversely and materially affecting a sector of the economy,
productivity, competition, jobs, the environment, public health or
safety, or state, local or tribal governments or communities (also
referred to as ``economically significant''); (2) creating a serious
inconsistency or otherwise interfering with an action taken or planned
by another agency; (3) materially altering the budgetary impacts of
entitlement grants, user fees, or loan programs or the rights and
obligations of recipients thereof; or (4) raising novel legal or policy
issues arising out of legal mandates, the President's priorities, or
the principles set forth in the Executive Order.
A regulatory impact analysis (RIA) must be prepared for major rules
with economically significant effects ($100 million or more in any 1
year). We estimate the total impact of the policy updates described in
this final rule by comparing the estimated payments in FY 2019 with
those in FY 2018. This analysis results in an estimated $105 million
increase for FY 2019 IRF PPS
[[Page 38567]]
payments. Additionally we estimate that costs associated with the
proposals to revise certain IRF coverage requirements and update the
reporting requirements under the IRF quality reporting program result
in an estimated $23 million reduction in costs in FY 2019 for IRFs. We
also estimate that the provisions in this final rule will result in an
estimated $18.5 million reduction in Medicare Part B spending from
physicians billing one fewer visit to Medicare Part B. We estimate that
this rulemaking is ``economically significant'' as measured by the $100
million threshold, and hence also a major rule under the Congressional
Review Act. Also, the rule has been reviewed by OMB. Accordingly, we
have prepared a Regulatory Impact Analysis that, to the best of our
ability, presents the costs and benefits of the rulemaking.
C. Anticipated Effects
1. Effects on IRFs
The RFA requires agencies to analyze options for regulatory relief
of small entities, if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, small entities
include small businesses, nonprofit organizations, and small
governmental jurisdictions. Most IRFs and most other providers and
suppliers are small entities, either by having revenues of $7.5 million
to $38.5 million or less in any 1 year depending on industry
classification, or by being nonprofit organizations that are not
dominant in their markets. (For details, see the Small Business
Administration's final rule that set forth size standards for health
care industries, at 65 FR 69432 at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.pdf, effective March 26, 2012 and
updated on February 26, 2016.) Because we lack data on individual
hospital receipts, we cannot determine the number of small proprietary
IRFs or the proportion of IRFs' revenue that is derived from Medicare
payments. Therefore, we assume that all IRFs (an approximate total of
1,120 IRFs, of which approximately 55 percent are nonprofit facilities)
are considered small entities and that Medicare payment constitutes the
majority of their revenues. The HHS generally uses a revenue impact of
3 to 5 percent as a significance threshold under the RFA. As shown in
Table 14, we estimate that the net revenue impact of this final rule on
all IRFs is to increase estimated payments by approximately 1.3
percent. The rates and policies set forth in this final rule will not
have a significant impact (not greater than 3 percent) on a substantial
number of small entities. Medicare Administrative Contractors are not
considered to be small entities. Individuals and states are not
included in the definition of a small entity. In addition, section
1102(b) of the Act requires us to prepare a regulatory impact analysis
if a rule may have a significant impact on the operations of a
substantial number of small rural hospitals. This analysis must conform
to the provisions of section 604 of the RFA. For purposes of section
1102(b) of the Act, we define a small rural hospital as a hospital that
is located outside of a Metropolitan Statistical Area and has fewer
than 100 beds. As discussed in detail below in this section, the rates
and policies set forth in this final rule will not have a significant
impact (not greater than 3 percent) on a substantial number of rural
hospitals based on the data of the 137 rural units and 11 rural
hospitals in our database of 1,126 IRFs for which data were available.
Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L.
104-04, enacted on March 22, 1995) (UMRA) also requires that agencies
assess anticipated costs and benefits before issuing any rule whose
mandates require spending in any 1 year of $100 million in 1995
dollars, updated annually for inflation. In 2018, that threshold is
approximately $150 million. This final rule does not mandate any
requirements for State, local, or tribal governments, or for the
private sector.
Executive Order 13132 establishes certain requirements that an
agency must meet when it issues a proposed rule (and subsequent final
rule) that imposes substantial direct requirement costs on state and
local governments, preempts state law, or otherwise has federalism
implications. As stated, this final rule will not have a substantial
effect on state and local governments, preempt state law, or otherwise
have a federalism implication.
Executive Order 13771, titled Reducing Regulation and Controlling
Regulatory Costs, was issued on January 30, 2017 and requires that the
costs associated with significant new regulations ``shall, to the
extent permitted by law, be offset by the elimination of existing costs
associated with at least two prior regulations.'' This final rule is
considered an E.O. 13771 deregulatory action. We estimate that this
rule would generate $27.24 million in annualized cost savings,
discounted at 7 percent relative to year 2016, over a perpetual time
horizon. Details on the estimated costs savings of this rule can be
found in the preceding analyses.
2. Detailed Economic Analysis
This final rule updates to the IRF PPS rates contained in the FY
2018 IRF PPS final rule (82 FR 36238). Specifically, this final rule
updates the CMG relative weights and average length of stay values, the
wage index, and the outlier threshold for high-cost cases. This final
rule applies a MFP adjustment to the FY 2019 IRF market basket increase
factor in accordance with section 1886(j)(3)(C)(ii)(I) of the Act, and
a 0.75 percentage point reduction to the FY 2019 IRF market basket
increase factor in accordance with sections 1886(j)(3)(C)(ii)(II) and
(D)(v) of the Act. Further, this final rule contains revisions to
remove the FIM\TM\ instrument and associated Function Modifiers from
the IRF-PAI beginning in FY 2020, revise certain IRF coverage
requirements, and revises and updates the IRF quality reporting
requirements that are expected to result in some additional financial
effects on IRFs. In addition, section X.J. of this final rule discusses
the implementation of the required 2 percentage point reduction of the
market basket increase factor for any IRF that fails to meet the IRF
quality reporting requirements, in accordance with section 1886(j)(7)
of the Act.
We estimate that the impact of the changes and updates described in
this final rule will be a net estimated increase of $105 million in
payments to IRF providers. This estimate does not include the
implementation of the required 2 percentage point reduction of the
market basket increase factor for any IRF that fails to meet the IRF
quality reporting requirements (as discussed in section X.J. of this
final rule). The impact analysis in Table 14 of this final rule
represents the projected effects of the updates to IRF PPS payments for
FY 2019 compared with the estimated IRF PPS payments in FY 2018. We
determine the effects by estimating payments while holding all other
payment variables constant. We use the best data available, but we do
not attempt to predict behavioral responses to these changes, and we do
not make adjustments for future changes in such variables as number of
discharges or case-mix.
We note that certain events may combine to limit the scope or
accuracy of our impact analysis, because such an analysis is future-
oriented and, thus, susceptible to forecasting errors because of other
changes in the forecasted impact time period. Some examples could be
legislative changes made by the Congress to the Medicare program that
would impact program funding, or changes specifically related to IRFs.
[[Page 38568]]
Although some of these changes may not necessarily be specific to the
IRF PPS, the nature of the Medicare program is such that the changes
may interact, and the complexity of the interaction of these changes
could make it difficult to predict accurately the full scope of the
impact upon IRFs.
In updating the rates for FY 2019, we are adopting standard annual
revisions described in this final rule (for example, the update to the
wage and market basket indexes used to adjust the federal rates). We
are also implementing a productivity adjustment to the FY 2019 IRF
market basket increase factor in accordance with section
1886(j)(3)(C)(ii)(I) of the Act, and a 0.75 percentage point reduction
to the FY 2017 IRF market basket increase factor in accordance with
sections 1886(j)(3)(C)(ii)(II) and (D)(v) of the Act. We estimate the
total increase in payments to IRFs in FY 2019, relative to FY 2018,
will be approximately $105 million.
This estimate is derived from the application of the FY 2019 IRF
market basket increase factor, as reduced by a productivity adjustment
in accordance with section 1886(j)(3)(C)(ii)(I) of the Act, and a 0.75
percentage point reduction in accordance with sections
1886(j)(3)(C)(ii)(II) and (D)(v) of the Act, which yields an estimated
increase in aggregate payments to IRFs of $110 million. Furthermore,
there is an additional estimated $5 million decrease in aggregate
payments to IRFs due to the proposed update to the outlier threshold
amount. Outlier payments are estimated to decrease from approximately
3.1 percent in FY 2018 to 3.0 percent in FY 2019. Therefore, summed
together, we estimate that these updates will result in a net increase
in estimated payments of $105 million from FY 2018 to FY 2019.
The effects of the updates that impact IRF PPS payment rates are
shown in Table 14. The following updates that affect the IRF PPS
payment rates are discussed separately below:
The effects of the update to the outlier threshold amount,
from approximately 3.1 percent to 3.0 percent of total estimated
payments for FY 2019, consistent with section 1886(j)(4) of the Act.
The effects of the annual market basket update (using the
IRF market basket) to IRF PPS payment rates, as required by section
1886(j)(3)(A)(i) and sections 1886(j)(3)(C) and (D) of the Act,
including a productivity adjustment in accordance with section
1886(j)(3)(C)(i)(I) of the Act, and a 0.75 percentage point reduction
in accordance with sections 1886(j)(3)(C)(ii)(II) and (D)(v) of the
Act.
The effects of applying the budget-neutral labor-related
share and wage index adjustment, as required under section 1886(j)(6)
of the Act.
The effects of the budget-neutral changes to the CMG
relative weights and average length of stay values, under the authority
of section 1886(j)(2)(C)(i) of the Act.
The total change in estimated payments based on the FY
2019 payment changes relative to the estimated FY 2018 payments.
3. Description of Table 14
Table 14 categorizes IRFs by geographic location, including urban
or rural location, and location for CMS's 9 Census divisions (as
defined on the cost report) of the country. In addition, the table
divides IRFs into those that are separate rehabilitation hospitals
(otherwise called freestanding hospitals in this section), those that
are rehabilitation units of a hospital (otherwise called hospital units
in this section), rural or urban facilities, ownership (otherwise
called for-profit, non-profit, and government), by teaching status, and
by disproportionate share patient percentage (DSH PP). The top row of
Table 14 shows the overall impact on the 1,126 IRFs included in the
analysis.
The next 12 rows of Table 14 contain IRFs categorized according to
their geographic location, designation as either a freestanding
hospital or a unit of a hospital, and by type of ownership; all urban,
which is further divided into urban units of a hospital, urban
freestanding hospitals, and by type of ownership; and all rural, which
is further divided into rural units of a hospital, rural freestanding
hospitals, and by type of ownership. There are 978 IRFs located in
urban areas included in our analysis. Among these, there are 709 IRF
units of hospitals located in urban areas and 269 freestanding IRF
hospitals located in urban areas. There are 148 IRFs located in rural
areas included in our analysis. Among these, there are 137 IRF units of
hospitals located in rural areas and 11 freestanding IRF hospitals
located in rural areas. There are 389 for-profit IRFs. Among these,
there are 349 IRFs in urban areas and 40 IRFs in rural areas. There are
619 non-profit IRFs. Among these, there are 532 urban IRFs and 87 rural
IRFs. There are 118 government-owned IRFs. Among these, there are 97
urban IRFs and 21 rural IRFs.
The remaining four parts of Table 14 show IRFs grouped by their
geographic location within a region, by teaching status, and by DSH PP.
First, IRFs located in urban areas are categorized for their location
within a particular one of the nine Census geographic regions. Second,
IRFs located in rural areas are categorized for their location within a
particular one of the nine Census geographic regions. In some cases,
especially for rural IRFs located in the New England, Mountain, and
Pacific regions, the number of IRFs represented is small. IRFs are then
grouped by teaching status, including non-teaching IRFs, IRFs with an
intern and resident to average daily census (ADC) ratio less than 10
percent, IRFs with an intern and resident to ADC ratio greater than or
equal to 10 percent and less than or equal to 19 percent, and IRFs with
an intern and resident to ADC ratio greater than 19 percent. Finally,
IRFs are grouped by DSH PP, including IRFs with zero DSH PP, IRFs with
a DSH PP less than 5 percent, IRFs with a DSH PP between 5 and less
than 10 percent, IRFs with a DSH PP between 10 and 20 percent, and IRFs
with a DSH PP greater than 20 percent.
The estimated impacts of each policy described in this rule to the
facility categories listed are shown in the columns of Table 14. The
description of each column is as follows:
Column (1) shows the facility classification categories.
Column (2) shows the number of IRFs in each category in
our FY 2019 analysis file.
Column (3) shows the number of cases in each category in
our FY 2019 analysis file.
Column (4) shows the estimated effect of the adjustment to
the outlier threshold amount.
Column (5) shows the estimated effect of the update to the
IRF labor-related share and wage index, in a budget-neutral manner.
Column (6) shows the estimated effect of the update to the
CMG relative weights and average length of stay values, in a budget-
neutral manner.
Column (7) compares our estimates of the payments per
discharge, incorporating all of the policies reflected in this final
rule for FY 2019 to our estimates of payments per discharge in FY 2018.
The average estimated increase for all IRFs is approximately 1.3
percent. This estimated net increase includes the effects of the IRF
market basket increase factor for FY 2019 of 2.9 percent, reduced by a
productivity adjustment of 0.8 percentage point in accordance with
section 1886(j)(3)(C)(ii)(I) of the Act, and further reduced by 0.75
percentage point in accordance with sections 1886(j)(3)(C)(ii)(II) and
(D)(v) of the Act.
[[Page 38569]]
It also includes the approximate 0.1 percent overall decrease in
estimated IRF outlier payments from the update to the outlier threshold
amount. Since we are making the updates to the IRF wage index and the
CMG relative weights in a budget-neutral manner, they will not be
expected to affect total estimated IRF payments in the aggregate.
However, as described in more detail in each section, they will be
expected to affect the estimated distribution of payments among
providers.
Table 14--IRF Impact Table for FY 2019
[Columns 4 through 7 in percentage]
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2019 CBSA
Facility classification Number of Number of Outlier wage index and CMG weights Total percent
IRF's cases labor-share change \1\
(1) (2) (3) (4) (5) (6) (7)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total................................................... 1,126 403,341 -0.1 0.0 0.0 1.3
Urban unit.............................................. 709 170,586 -0.1 0.0 0.0 1.2
Rural unit.............................................. 137 22,274 -0.1 -0.3 0.1 1.0
Urban hospital.......................................... 269 206,108 0.0 0.0 0.0 1.3
Rural hospital.......................................... 11 4,373 0.0 0.2 0.1 1.6
Urban For-Profit........................................ 349 203,684 0.0 0.1 0.0 1.3
Rural For-Profit........................................ 40 8,557 -0.1 0.1 0.1 1.4
Urban Non-Profit........................................ 532 150,179 -0.1 0.0 0.0 1.2
Rural Non-Profit........................................ 87 14,952 -0.1 -0.3 0.1 0.9
Urban Government........................................ 97 22,831 -0.2 -0.1 0.0 1.2
Rural Government........................................ 21 3,138 -0.1 -0.2 0.1 1.2
Urban................................................... 978 376,694 -0.1 0.0 0.0 1.3
Rural................................................... 148 26,647 -0.1 -0.2 0.1 1.1
Urban by region:
Urban New England................................... 29 16,673 -0.1 0.0 0.0 1.3
Urban Middle Atlantic............................... 141 53,414 -0.1 0.0 0.0 1.2
Urban South Atlantic................................ 112 49,765 -0.1 -0.3 0.0 0.9
Urban East North Central............................ 172 48,719 -0.1 0.1 0.1 1.4
Urban East South Central............................ 55 35,817 0.0 0.0 -0.1 1.3
Urban West North Central............................ 109 37,719 -0.1 -0.1 0.0 1.2
Urban West South Central............................ 184 82,002 -0.1 0.4 0.0 1.7
Urban Mountain...................................... 78 28,796 -0.1 -0.3 0.0 1.0
Urban Pacific....................................... 98 23,789 -0.2 0.0 0.0 1.2
Rural by region:
Rural New England................................... 5 1,282 -0.1 1.9 0.0 3.2
Rural Middle Atlantic............................... 11 1,450 -0.1 -0.4 0.0 0.8
Rural South Atlantic................................ 13 2,716 0.0 -0.5 0.0 0.8
Rural East North Central............................ 25 4,558 -0.1 -0.6 0.1 0.7
Rural East South Central............................ 15 3,721 0.0 -0.2 0.1 1.3
Rural West North Central............................ 29 4,702 -0.1 0.1 0.1 1.4
Rural West South Central............................ 40 7,161 -0.1 -0.4 0.1 0.9
Rural Mountain.......................................... 6 704 -0.2 0.4 0.2 1.7
Rural Pacific........................................... 4 353 -0.4 -0.3 0.0 0.7
Teaching status:
Non-teaching........................................ 1021 357,816 -0.1 0.0 0.0 1.3
Resident to A DC less than 10%...................... 62 33,936 -0.1 0.0 0.0 1.2
Resident to A DC 10%-19%............................ 29 9,489 -0.1 0.1 0.1 1.3
Resident to A DC greater than 19%................... 14 2,100 -0.1 0.5 0.0 1.7
Disproportionate share patient percentage (DSH PP):
DSH PP = 0%......................................... 24 4,936 -0.3 0.3 0.0 1.3
DSH PP <5%.......................................... 150 62,891 -0.1 0.0 0.0 1.2
DSH PP 5%-10%....................................... 298 123,109 -0.1 0.1 0.0 1.3
DSH PP 10%-20%...................................... 372 135,115 -0.1 0.0 0.0 1.3
DSH PP greater than 20%............................. 282 77,290 -0.1 -0.1 0.0 1.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ This column includes the impact of the updates in columns (4), (5), and (6) above, and of the IRF market basket increase factor for FY 2019 (2.9
percent), reduced by 0.8 percentage point for the productivity adjustment as required by section 1886(j)(3)(C)(ii)(I) of the Act, and reduced by 0.75
percentage point in accordance with sections 1886(j)(3)(C)(ii)(II) and -(D)(v) of the Act.
4. Impact of the Update to the Outlier Threshold Amount
The estimated effects of the update to the outlier threshold
adjustment are presented in column 4 of Table 14. In the FY 2018 IRF
PPS final rule (82 FR 36238), we used FY 2016 IRF claims data (the
best, most complete data available at that time) to set the outlier
threshold amount for FY 2018 so that estimated outlier payments would
equal 3 percent of total estimated payments for FY 2018.
For the FY 2019 IRF PPS proposed rule (83 FR 20987), we used
preliminary FY 2017 IRF claims data, and, based on that preliminary
analysis, we estimated that IRF outlier payments as a percentage of
total estimated IRF payments would be 3.4 percent in FY 2018. As we
typically do between the proposed and final rules each year, we updated
our FY 2017 IRF claims data to
[[Page 38570]]
ensure that we are using the most recent available data in setting IRF
payments. Therefore, based on updated analysis of the most recent IRF
claims data for this final rule, we now estimate that IRF outlier
payments as a percentage of total estimated IRF payments are 3.1
percent in FY 2018. Thus, we are adjusting the outlier threshold amount
in this final rule to set total estimated outlier payments equal to 3
percent of total estimated payments in FY 2019. The estimated change in
total IRF payments for FY 2019, therefore, includes an approximate 0.1
percent decrease in payments because the estimated outlier portion of
total payments is estimated to decrease from approximately 3.1 percent
to 3 percent.
The impact of this outlier adjustment update (as shown in column 4
of Table 14) is to decrease estimated overall payments to IRFs by about
0.1 percent. We estimate the largest decrease in payments from the
update to the outlier threshold amount to be 0.4 percent for rural IRFs
in the Pacific region.
5. Impact of the CBSA Wage Index and Labor-Related Share
In column 5 of Table 14, we present the effects of the budget-
neutral update of the wage index and labor-related share. The changes
to the wage index and the labor-related share are discussed together
because the wage index is applied to the labor-related share portion of
payments, so the changes in the two have a combined effect on payments
to providers. As discussed in section VI.C. of this final rule, we are
updating the labor-related share from 70.7 percent in FY 2018 to 70.5
percent in FY 2019.
6. Impact of the Update to the CMG Relative Weights and Average Length
of Stay Values
In column 6 of Table 14, we present the effects of the budget-
neutral update of the CMG relative weights and average length of stay
values. In the aggregate, we do not estimate that these updates will
affect overall estimated payments of IRFs. However, we do expect these
updates to have small distributional effects.
7. Effects of the Removal of the FIM\TM\ Instrument and Associated
Function Modifiers From the IRF-PAI Beginning in FY 2020
As discussed in section VIII. of this final rule, we are removing
the FIM\TM\ Instrument and Associated Function Modifiers from the IRF-
PAI beginning in FY 2020. We estimate that removal of these data items
from the IRF-PAI will reduce administrative burden on IRF providers and
reduce the costs incurred by IRFs by $10.5 million for FY 2020.
8. Effects of Revisions to Certain IRF PPS Requirements
As discussed in section IX. of this final rule, in response to the
RFI, we are removing and amending certain IRF coverage criteria
requirements that are overly burdensome on IRF providers beginning in
FY 2019, that is, all IRF discharges on or after October 1, 2018.
We estimate the cost savings associated with our change to allow
the post-admission physician evaluation to count as one of the required
face-to-face physician visits, as discussed in section IX.A of this
final rule, in the following way. We first estimate that the post-
admission physician evaluation takes approximately 60 minutes to
complete and the required face-to-face physician visits take, on
average, 30 minutes each to complete. Both of these requirements must
be fulfilled by a rehabilitation physician. To estimate the burden
reduction of this change, therefore, we obtained the hourly wage rate
for a physician (there was not a specific wage rate for a
rehabilitation physician) from the Bureau of Labor Statistics (http://www.bls.gov/ooh/healthcare/home.htm) to be $100.00. The hourly wage
rate including fringe benefits and overhead is $200.00.
In FY 2017, we estimate that there were approximately 1,126 total
IRFs and on average 358 discharges per IRF annually. Therefore, there
were an estimated seven patients (358 discharges/52 weeks) at the IRF
per week. The rehabilitation physician spends 358 hours (60 minutes x
358 discharges) annually completing the post-admission physician
evaluation. If on average each IRF has seven patients per week and each
face-to-face visit takes an estimated 30 minutes for the rehabilitation
physician to complete, annually the rehabilitation physician spends an
estimated 546 hours ((7 patients x 3 visits x 0.5 hours) x 52 weeks)
completing the required face-to-face physician visits. On average, a
rehabilitation physician currently spends 903 hours (357 hours + 546
hours) annually completing post-admission physician evaluations and the
required face-to-face physician visits.
If we allow the post-admission physician evaluation to count as one
of the face-to-face required physician visits, and to be documented as
such in the IRF medical record, we would need to estimate the average
time spent on one face-to-face visit ((7 patients x 1 visit x 0.5
hours) x 52 weeks). Removing one of the face-to-face visits required in
the first week of the IRF admission will save the rehabilitation
physician approximately 182 hours ((7 patients x 1 visit x 0.5 hours) x
52 weeks) annually per IRF. This is a savings of 204,932 hours across
all IRFs annually (1,126 IRFs x 182 hours).
To estimate the total cost savings per IRF annually, we multiply
182 hours by $200.00 (average physician's salary doubled to account for
fringe and overhead costs). Therefore, we can estimate the total cost
savings per IRF will be $36,400 annually. We estimate that the total
cost savings for allowing the post-admission physician evaluation to
count as one of the required face-to-face physician visits, will be $41
million (1,126 IRFs x $36,400) annually across the IRF setting. As
described above, based on stakeholder feedback, we anticipate that
rehabilitation physicians in a majority of IRFs will adopt this policy
change; because there is some uncertainty, we assume in our burden
reduction estimate that rehabilitation physicians in half of all IRFs
will change their visiting practices accordingly. Therefore, we now
estimate that the total cost savings for allowing the post-admission
physician evaluation to count as one of the required face-to-face
physician visits will be $20.5 million (563 IRFs x $36,400).
We also note that fewer physician visits will result in Medicare
savings from lower Part B payments to physicians under the physician
fee schedule. The national average Medicare Part B payment for a 30
minute moderate intensity ``subsequent'' visit (versus an initial
visit) is $93. Therefore, if the estimated number of discharges per IRF
is 358 and we multiply that by the estimated cost of one physician
visit, then we estimate that the reduction in Part B billing per IRF
would be approximately $33,000. Across the Medicare program for all
IRFs, we estimate it would be approximately $37 million in Part B
savings. However, we reduce this estimate by 50 percent, as we assume
that only half of IRFs will adopt this policy. Therefore, we estimate
that Medicare Part B payments to rehabilitation physicians in IRFs will
be reduced by approximately $18.5 million.
We do not estimate a cost savings in removing the admission order
coverage criteria requirements as IRFs are still required to comply
with the enforcement of the admission requirements located in
Sec. Sec. 482.24(c), 482.12(c) and 412.3. Any increase in Medicare
payments due to the change would be negligible given the anticipated
low volume of claims that
[[Page 38571]]
would be payable under this revised policy that would not have been
paid under the current policy. Therefore, we believe that the reduction
of burden in this removal is in reducing the redundancy of requirements
only.
Therefore, we estimate that the removal and updates to these
requirements will reduce unnecessary regulatory and administrative
burden on IRF providers and reduce the costs incurred by IRFs by $20.5
million for FY 2019. Additionally, we estimate that the removal and
updates to these requirements will also reduce Medicare Part B payments
by $18.5 million for FY 2019.
Though we are unsure exactly how many, we recognize that some IRFs
may have facility protocols in place that exceed our IRF requirements
regarding how many times the rehabilitation physician must visit each
patient per week and document these visits in the IRF medical record.
While our requirement is a minimum of three face-to-face visits a week,
we understand that it is not uncommon for IRFs institute a facility
protocol requiring the rehabilitation physician to see the patient
daily. To the extent that some IRFs are choosing to exceed our
requirements, we recognize that the savings estimate could be lower
than what we have projected.
9. Effects of the Requirements for the IRF QRP for FY 2020
In accordance with section 1886(j)(7) of the Act, we will reduce by
2 percentage points the market basket increase factor otherwise
applicable to an IRF for a fiscal year if the IRF does not comply with
the requirements of the IRF QRP for that fiscal year. In section VII.K
of this final rule, we discuss the method for applying the 2 percentage
point reduction to IRFs that fail to meet the IRF QRP requirements.
As discussed in section X.4. of this final rule, we are removing
two measures from the IRF QRP: Percent of Residents or Patients Who
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
(Short Stay) (NQF #0680) and the National Healthcare Safety Network
(NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant
Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716).
We describe the estimated burden and cost reductions for both of
these measures in section XIV.C of this rule. In summary, the finalized
IRF QRP measure removals will result in a burden reduction of $2,223.26
per IRF annually, and $2,503,629.76 for all IRFs annually.
We intend to continue closely monitoring the effects of the IRF QRP
on IRFs and to help perpetuate successful reporting outcomes through
ongoing stakeholder education, national trainings, IRF announcements,
website postings, CMS Open Door Forums, and general and technical help
desks.
D. Alternatives Considered
The following is a discussion of the alternatives considered for
the IRF PPS updates contained in this final rule.
Section 1886(j)(3)(C) of the Act requires the Secretary to update
the IRF PPS payment rates by an increase factor that reflects changes
over time in the prices of an appropriate mix of goods and services
included in the covered IRF services. Thus, we did not consider
alternatives to updating payments using the estimated IRF market basket
increase factor for FY 2019. However, as noted previously in this final
rule, section 1886(j)(3)(C)(ii)(I) of the Act requires the Secretary to
apply a productivity adjustment to the market basket increase factor
for FY 2019, and sections 1886(j)(3)(C)(ii)(II) and 1886(j)(3)(D)(v) of
the Act require the Secretary to apply a 0.75 percentage point
reduction to the market basket increase factor for FY 2019. Thus, in
accordance with section 1886(j)(3)(C) of the Act, we are updating the
IRF federal prospective payments in this final rule by 1.35 percent
(which equals the 2.9 percent estimated IRF market basket increase
factor for FY 2019 reduced by a 0.8 percentage point productivity
adjustment as required by section 1886(j)(3)(C)(ii)(I) of the Act and
further reduced by 0.75 percentage point).
We considered maintaining the existing CMG relative weights and
average length of stay values for FY 2019. However, in light of
recently available data and our desire to ensure that the CMG relative
weights and average length of stay values are as reflective as possible
of recent changes in IRF utilization and case-mix, we believe that it
is appropriate to update the CMG relative weights and average length of
stay values at this time to ensure that IRF PPS payments continue to
reflect as accurately as possible the current costs of care in IRFs.
We considered updating facility-level adjustment factors for FY
2019. However, as discussed in more detail in the FY 2015 final rule
(79 FR 45872), we believe that freezing the facility-level adjustments
at FY 2014 levels for FY 2015 and all subsequent years (unless and
until the data indicate that they need to be further updated) will
allow us an opportunity to monitor the effects of the substantial
changes to the adjustment factors for FY 2014, and will allow IRFs time
to adjust to the previous changes.
We considered maintaining the existing outlier threshold amount for
FY 2019. However, analysis of updated FY 2019 data indicates that
estimated outlier payments would be higher than 3 percent of total
estimated payments for FY 2019, by approximately 0.1 percent, unless we
updated the outlier threshold amount. Consequently, we are adjusting
the outlier threshold amount in this final rule to reflect a 0.1
percent decrease thereby setting the total outlier payments equal to 3
percent, instead of 3.1 percent, of aggregate estimated payments in FY
2019.
We considered not removing the FIMTM instrument and
associated Function Modifiers from the IRF-PAI in this final rule.
However, in light of recently available data located in the Quality
Indicators section of the IRF-PAI, we believe that removal of the
FIMTM instrument and associated Function Modifiers is
appropriate at this time. As the data items located in the Quality
Indicators section of the IRF-PAI are now collected for all IRFs, we
believe that the collection of the FIM data is duplicative and creates
undue burden on providers. Consequently, we are removing these data
items from the IRF-PAI beginning with FY 2020. Additionally, the
removal of the FIMTM Instrument and associated Function
Modifiers necessitates the incorporation of the data items from the
Quality Indicators section of the IRF-PAI into the CMG classification
system. To ensure that the CMGs, relative weights, and average length
of stay values are as reflective as possible of recent changes in IRF
utilization and case-mix, we believe that it is appropriate to
incorporate the data items from the Quality Indicators section of the
IRF-PAI into the development of the CMGs beginning with FY 2020.
We considered not revising certain IRF PPS requirements, or
revising them partially, in order to reduce burden in this final rule.
Specifically, we considered not combining the post-admission physician
evaluation with the required face-to-face physician visits, and
continuing to require documentation of the post-admission physician
evaluation and all three face-to-face physician visits in the IRF
medical record in the first week of the patient's IRF stay. However,
through the request for information, it was suggested that we focus on
removing documentation and administrative burden in IRFs and we wanted
to assist by combining two documentation requirements into one, thus
reducing
[[Page 38572]]
the medical record documentation requirements that the rehabilitation
physician would need to meet. Additionally, we also considered not
removing the admission order requirement from the IRF medical record.
However, we felt that the requirement was duplicative and could be met
by other requirements that are currently in place. Lastly, we
considered not allowing rehabilitation physicians to lead the
interdisciplinary team meeting remotely via other forms of
communication without additional documentation of this in the IRF
medical record. We also considered only relaxing this requirement for
rural IRFs, as some of the commenters suggested. However, we believe
that this policy change is appropriate and beneficial for all IRFs, not
just rural, so we decided to finalize the policy as proposed. As we
believe that rehabilitation physicians rarely conduct interdisciplinary
team meetings remotely, we do not believe that this policy has
significant financial implications for IRFs. However, we believe that
it does advance the Agency's goal of placing patients over paperwork.
Therefore, after the response that we received from providers
regarding the RFI solicitation and comments that we received from the
FY 2019 IRF PPS proposed rule, we believed that these specific coverage
requirements were areas in which we could reduce unnecessary regulatory
and administrative burden on IRF providers, while ensuring that IRF
patients would continue to receive adequate care.
E. Regulatory Review Costs
If regulations impose administrative costs on private entities,
such as the time needed to read and interpret this final rule, we
should estimate the cost associated with regulatory review. Due to the
uncertainty involved with accurately quantifying the number of entities
that will review the rule, we assume that the total number of unique
commenters on FY 2019 IRF PPS proposed rule will be the number of
reviewers of this final rule. We acknowledge that this assumption may
understate or overstate the costs of reviewing this final rule. It is
possible that not all commenters reviewed the FY 2019 IRF PPS proposed
rule in detail, and it is also possible that some reviewers chose not
to comment on the proposed rule. For these reasons we thought that the
number of past commenters would be a fair estimate of the number of
reviewers of this rule.
We also recognize that different types of entities are in many
cases affected by mutually exclusive sections of this final rule, and
therefore for the purposes of our estimate we assume that each reviewer
reads approximately 50 percent of the rule. We sought comments on this
assumption.
Using the wage information from the BLS for medical and health
service managers (Code 11-9111), we estimate that the cost of reviewing
this rule is $107.38 per hour, including overhead and fringe benefits
(https://www.bls.gov/oes/current/oes_nat.htm). Assuming an average
reading speed, we estimate that it would take approximately 2 hours for
the staff to review half of this final rule. For each IRF that reviews
the rule, the estimated cost is $214.76 (2 hours x $107.38). Therefore,
we estimate that the total cost of reviewing this regulation is
$23,408.84 ($214.76 x 109 reviewers).
F. Accounting Statement and Table
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/sites/default/files/omb/assets/omb/circulars/a004/a-4.pdf), in Table 15, we have prepared an accounting statement showing
the classification of the expenditures associated with the provisions
of this final rule. Table 15 provides our best estimate of the increase
in Medicare payments under the IRF PPS as a result of the updates
presented in this final rule based on the data for 1,126 IRFs in our
database. In addition, Table 15 presents the costs associated with the
new IRF quality reporting program requirements for FY 2019.
Table 15--Accounting Statement: Classification of Estimated Expenditure
----------------------------------------------------------------------------------------------------------------
Change in Estimated Transfers from FY 2018 IRF PPS to FY 2019 IRF PPS
-----------------------------------------------------------------------------------------------------------------
Category Transfers
----------------------------------------------------------------------------------------------------------------
Annualized Monetized Transfers.......... $105 million.
From Whom to Whom?...................... Federal Government to IRF Medicare Providers.
----------------------------------------------------------------------------------------------------------------
Change in Estimated Costs
----------------------------------------------------------------------------------------------------------------
Category Costs
----------------------------------------------------------------------------------------------------------------
Annualized monetized cost in FY 2019 for Reduction of $20.5 million.
IRFs due to the removal of certain IRF
coverage requirements.
Annualized monetized cost in FY 2020 for Reduction of $10.5 million.
IRFs due to the removal of FIM\TM\
instrument and associated Function
Modifiers from the IRF[dash]PAI.
Annualized monetized cost in FY 2019 for Reduction of $2.5 million.
IRFs due to new quality reporting
program requirements.
----------------------------------------------------------------------------------------------------------------
G. Conclusion
Overall, the estimated payments per discharge for IRFs in FY 2019
are projected to increase by 1.3 percent, compared with the estimated
payments in FY 2018, as reflected in column 7 of Table 14.
IRF payments per discharge are estimated to increase by 1.3 percent
in urban areas and 1.1 percent in rural areas, compared with estimated
FY 2018 payments. Payments per discharge to rehabilitation units are
estimated to increase 1.2 percent in urban areas and 1.0 percent in
rural areas. Payments per discharge to freestanding rehabilitation
hospitals are estimated to increase 1.3 percent in urban areas and
increase 1.6 percent in rural areas.
Overall, IRFs are estimated to experience a net increase in
payments as a result of the policies in this final rule. The largest
payment increase is estimated to be a 3.2 percent increase for rural
IRFs located in the New England region. The analysis above, together
with the remainder of this preamble, provides a Regulatory Impact
Analysis.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
[[Page 38573]]
List of Subjects in 42 CFR Part 412
Administrative practice and procedure, Health facilities, Medicare,
Puerto Rico, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the Department of Health
and Human Services amends 42 CFR chapter IV as set forth below:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
0
1. The authority citation for part 412 is revised to read as follows:
Authority: 42 U.S.C. 1302 and 1395hh.
Sec. 412.606 [Amended]
0
2. Section 412.606 is amended by--
0
a. Removing paragraph (a); and
0
b. Redesignating paragraphs (b) and (c) as paragraphs (a) and (b).
0
3. Section 412.622 is amended by--
0
a. Revising paragraph (a)(3)(iv);
0
b. Redesignating paragraphs (a)(5)(A) through (C) as paragraphs
(a)(5)(i) through (iii); and
0
c. Revising newly redesignated paragraph (a)(5)(i).
The revisions read as follows:
Sec. 412.622 Basis of payment.
(a) * * *
(3) * * *
(iv) Requires physician supervision by a rehabilitation physician,
defined as a licensed physician with specialized training and
experience in inpatient rehabilitation. The requirement for medical
supervision means that the rehabilitation physician must conduct face-
to-face visits with the patient at least 3 days per week throughout the
patient's stay in the IRF to assess the patient both medically and
functionally, as well as to modify the course of treatment as needed to
maximize the patient's capacity to benefit from the rehabilitation
process. The post-admission physician evaluation described in paragraph
(a)(4)(ii) of this section may count as one of the face-to-face visits.
* * * * *
(5) * * *
(i) The team meetings are led by a rehabilitation physician as
defined in paragraph (a)(3)(iv) of this section, and further consist of
a registered nurse with specialized training or experience in
rehabilitation; a social worker or case manager (or both); and a
licensed or certified therapist from each therapy discipline involved
in treating the patient. All team members must have current knowledge
of the patient's medical and functional status. The rehabilitation
physician may lead the interdisciplinary team meeting remotely via a
mode of communication such as video or telephone conferencing.
* * * * *
0
4. Section 412.624 is amended by revising paragraph (c)(4)(i) and
adding paragraph (c)(4)(iii) to read as follows:
Sec. 412.624 Methodology for calculating the Federal prospective
payment rates.
* * * * *
(c) * * *
(4) * * *
(i) In the case of an IRF that is paid under the prospective
payment system specified in Sec. 412.1(a)(3) that does not submit
quality data to CMS in accordance with Sec. 412.634, the applicable
increase factor specified in paragraph (a)(3) of this section, after
application of subparagraphs (C)(iii) and (D) of section 1886(j)(3) of
the Act, is reduced by 2 percentage points.
* * * * *
(iii) The 2 percentage point reduction described in paragraph
(c)(4)(i) of this section may result in the applicable increase factor
specified in paragraph (a)(3) of this section being less than 0.0 for a
fiscal year, and may result in payment rates under the prospective
payment system specified in Sec. 412.1(a)(3) for a fiscal year being
less than such payment rates for the preceding fiscal year.
* * * * *
0
5. Section 412.634 is amended by revising paragraphs (b), (d)(1) and
(5) to read as follows:
Sec. 412.634 Requirements under the Inpatient Rehabilitation Facility
(IRF) Quality Reporting Program (QRP).
* * * * *
(b) Submission requirements. (1) IRFs must submit to CMS data on
measures specified under sections 1886(j)(7)(D), 1899B(c)(1),
1899B(d)(1) of the Act, and standardized patient assessment data
required under section 1899B(b)(1) of the Act, as applicable. Such data
must be submitted in the form and manner, and at a time, specified by
CMS.
(2) CMS may remove a quality measure from the IRF QRP based on one
or more of the following factors:
(i) Measure performance among IRFs is so high and unvarying that
meaningful distinctions in improvements in performance can no longer be
made;
(ii) Performance or improvement on a measure does not result in
better patient outcomes;
(iii) A measure does not align with current clinical guidelines or
practice;
(iv) The availability of a more broadly applicable (across
settings, populations, or conditions) measure for the particular topic;
(v) The availability of a measure that is more proximal in time to
desired patient outcomes for the particular topic;
(vi) The availability of a measure that is more strongly associated
with desired patient outcomes for the particular topic;
(vii) The collection or public reporting of a measure leads to
negative unintended consequences other than patient harm;
(viii) The costs associated with a measure outweigh the benefit of
its continued use in the program.
* * * * *
(d) * * *
(1) IRFs that do not meet the requirement in paragraph (b) of this
section for a program year will receive a written notification of non-
compliance through at least one of the following methods: Quality
Improvement and Evaluation System Assessment Submission and Processing
(QIES ASAP) system, the United States Postal Service, or via an email
from the Medicare Administrative Contractor (MAC).
* * * * *
(5) CMS will notify IRFs, in writing, of its final decision
regarding any reconsideration request through at least one of the
following methods: QIES ASAP system, the United States Postal Service,
or via an email from the Medicare Administrative Contractor (MAC).
* * * * *
Dated: July 26, 2018.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
Dated: July 26, 2018.
Alex M. Azar II,
Secretary, Department of Health and Human Services.
[FR Doc. 2018-16517 Filed 7-31-18; 4:15 pm]
BILLING CODE 4120-01-P