Hospital Association of Pennsylvania > Advocacy > Federal Advocacy > Comment Letter to CMS on FY 2016 IRF PPS


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Comment Letter to CMS on FY 2016 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule

June 22, 2015

Andy Slavitt
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1624-P
P.O. Box 8013 Baltimore, MD 21244-1850

Re: CMS 1624-P, Proposed Fiscal year 2016 Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities

Dear Mr. Slavitt:

On behalf of The Hospital & Healthsystem Association of Pennsylvania (HAP), which represents approximately 240 member hospitals and health systems, we appreciate this opportunity to comment about the Centers for Medicare & Medicaid Services’ (CMS) fiscal year (FY) 2016 Inpatient Rehabilitation Facility (IRF) Prospective Payment System proposed rule.

Market Basket Update

CMS intends to use the 2012-based IRF market basket using Medicare cost report data for freestanding and hospital-based IRFs, which will result in a 2.7 percent market basket update totaling more than $550 million in payments. This $9,264,700 change is a 1.8 percent increase from the 2015 payment amount.

The market basket update does not account for the mandatory sequestration. The estimated impact of the sequestration on IRFs in Pennsylvania is a loss of $11,067,500.

Hospitals could face financial hardship as this calculation does not factor for outlier payments, Medicare Advantage patients, or modification in fee-for-service payments from hospitals participating in new demonstration project payment models. HAP encourages CMS to consider the fact that the proposed rule does not account for the 2 percent sequestration reduction to all lines of Medicare.

HAP urges CMS to postpone implementation of a new IRF-specific market basket until the agency can ensure it accurately reflects costs for freestanding and hospital-based IRFs.

Quality Reporting Program

These measures will be used to collect data for payment determinations:

  • NQF #1038 Catheter-associated urinary tract infection outcome measure – 2015 and beyond
  • NQF #0431 Influenza vaccination coverage among healthcare personnel – 2015 and beyond
  • #2505 All-cause unplanned readmission measure for 30 days post-discharge from IRFs – 2016 and beyond
  • NQF #6080 Percent of residents or patients who were assessed and appropriately given the seasonal influenza vaccine – 2016 and beyond
  • NQF #0678 Percent of residents or patients with pressure ulcers that are new or worsened – 2016 and beyond – 2017 and beyond
  • NQF #1716 NHSN facility-wide inpatient hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia outcome measure
  • NQF #1717 NHSN facility-wide inpatient hospital-onset clostridium difficile infection (CDI) outcome measure – 2017 and beyond
  • NQF #2502 All-cause unplanned readmission – 2018 and beyond

HAP supports the continued use of National Quality Forum (NQF)-endorsed National Healthcare Safety Network NQF #0138, Catheter-Associated Urinary Tract Infection (CAUTI) outcome measure, and NQF #0678, the risk-adjusted version of the pressure ulcer measure within the quality reporting program for IRFs.

HAP recommends removing persons with high-level spinal cord injuries from the CAUTI measure, as they are best served by foley catheters.

The influenza vaccination, NQF #0431, is not an outcomes measure and doesn’t address the goal of IRFs to improve function for the patients they treat. Consideration needs to be given to the reliability of the information from incoming patients as to whether they were already vaccinated.

History has shown the majority of patients admitted to the IRFs already have been vaccinated, especially patients transferring from the acute care hospital. HAP urges CMS to consider the additional reporting burden and the potential for patients to receive duplicative vaccinations, before requiring data collection on this measure for 2017.

HAP supports the addition of measures to improve quality outcomes, lower cost, and reduce readmissions as mandated by Section 3004(a) of the Patient Protection and Affordable Care Act (ACA) of 2010.

However, HAP recommends that CMS thoroughly evaluate each measure added to ensure new measures truly add to the overall quality of care. For example, the readmission measure does not adjust for socioeconomic factors beyond the control of the IRF.

Hospitals recognize the need to prevent readmissions, however, the needs are not uniform across all demographic and economic groups. It is imperative that the payment system recognizes this as well. Therefore, HAP supports risk adjustment to account for socioeconomic factors when calculating readmissions penalties.

CMS also is proposing to adopt six new quality measures to be collected and reported using the IRF patient assessment instrument (IRF-PAI):

  • NQF #0674 Percent of residents experience one or more falls with major injury (extended stay)
  • NQF #2631 LTCH patients with an admission and discharge functional assessment and a care plan that addresses function
  • NQF #2633 Change in self-care score
  • NQF #2634 Change in mobility score
  • NQF #2635 Discharge self-care score
  • NQF #2636 Discharge mobility score

HAP member hospitals have expressed concern around the time burden for data collection for quality measures. After doing an assessment, Pennsylvania IRF facilities fear that additional full-time equivalents will need to be hired, which causes a financial burden.

The continuity assessment record and evaluation (CARE) tool used simultaneously with the functional independent measures is very confusing because both systems are similar. Switching between the two could cause potential error.

This would result in unreliable and inaccurate data collection and potential safety risks. HAP recommends using consistent data collection and reporting for all quality measures, and streamlining the collection to reduce financial burden.

Thank you for consideration of our comments about the IRF prospective payment system proposed rule. If you have any questions, please feel free to contact me at (717) 561-5344, or Brian Smith, director of compliance, at (717) 561-5356.


Paula Bussard
Chief Strategy Officer

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