Medicare Long-Term Care Hospital Prospective Payment System

Transcription

1 Medicare Lng-Term Care Hspital Prspective Payment System August 22, 2016 Payment Rule Brief FINAL RULE Prgram Year: FFY 2017 Overview and Resurces On August 2, 2016 the Centers fr Medicare and Medicaid Services (CMS) released the display cpy f the federal fiscal year (FFY) 2017 final payment rule fr the Medicare Lng-Term Care Hspital Prspective Payment System (LTCH PPS). The final rule reflects the annual update t the Medicare fee-fr-service (FFS) LTCH payment rates and plicies. A display cpy f the final rule Federal Register (FR) and ther resurces related t the LTCH PPS is available n the CMS website at Payment/LngTermCareHspitalPPS/index.html. An nline versin f the final rule will be available n August 22 nd, 2016 at A brief f the final rule is prvided belw alng with display cpy page references fr additinal details. Prgram changes adpted by CMS will be effective fr discharges n r after Octber 1, 2016 unless therwise nted. Effect f BiBA and PAMA n the LTCH PPS DISPLAY pages The Bipartisan Budget Act (BiBA) f 2013 and Prtecting Access t Medicare Act (PAMA) f 2014 included several significant prvisins related t current and future LTCH PPS plicies and payment. The laws direct CMS t establish tw different types f LTCH PPS payment rates: the standard LTCH PPS payment rates and site-neutral LTCH PPS payment rates, which are based n the IPPS rates. LTCH discharges that meet certain clinical criteria (detailed belw) will cntinue t be paid at the standard LTCH PPS payment rates. LTCH discharges frm that d nt meet the established clinical criteria will be paid the new, lwer siteneutral payment rates (with sme specified exclusins). In last year s FFY 2016 LTCH final rule, CMS implemented a tw-year transitin fr the site-neutral payment rates, beginning with cst reprting perids that started n r after Octber 1, Fr the first year f the transitin, site-neutral payments are based n a 50/50 blend f LTCH PPS standard Federal payment rate and the LTCH PPS site neutral payment rate. FFY 2017 will be the secnd year f the 50/50 site-neutral transitin fr impacted cases. The fllwing is a brief summary f the mandates: 1 P a g e

2 Site Neutral Payments: BiBA mandates the use f site-neutral Inpatient Prspective Payment System (IPPS) equivalent payment rates fr LTCHs beginning FFY 2016 (with a tw-year phase-in). CMS uses the fllwing criteria in rder t identify cases eligible fr a standard LTCH PPS payment: The LTCH discharge des nt have a principal diagnsis relating t a psychiatric diagnsis r t rehabilitatin; A case must be immediately discharged frm an inpatient PPS hspital. This immediate discharge will be evidenced by the dates f discharge and admissin t the LTCH; and One r bth f these criteria: Must receive at least three days f care in an ICU r CCU during the prir hspital stay. CMS will use the full set f ICU and CCU revenue cdes when cunting a patient s ICU and CCU days during the prir acute care hspital stay; and/r The patient received at least 96 hurs f ventilatr services in the LTCH stay. As 2017 is the secnd year f the transitin, site-neutral cases will be paid a blend f the standard LTCH PPS rate and the applicable site-neutral rate. All applicable adjustments wuld apply t each f the rates cntributing t the blended payment. Fllwing this transitin perid, site-neutral cases wuld be paid fully under the site-neutral rates. CMS finalized that the site neutral payment rate is the lesser f either the IPPS cmparable per diem amunt, r 100 percent f the estimated cst f the case. The IPPS cmparable per diem payment amunt is capped at the lwer f the IPPS cmparable per diem amunt and the full cmparable amunt t what wuld therwise be paid under IPPS. In additin, BiBA mandates an IPPS equivalent payment rate fr ALL discharges fr LTCHs that fail t meet the applicable discharge threshld (less than 50% f patients fr whm the standard LTCH PPS payment is made). This mandate wuld be effective fr discharges ccurring in cst reprting perids during r after FFY The law includes a reinstatement prcess fr LTCHs that fail t meet the required discharge threshld percentage in a particular year. Fr calculating whether an LTCH r LTCH satellite meets the existing greater than 25-day average length f stay requirement, BiBA mandates the exclusin f cases paid at the site neutral rate and thse paid by Medicare Advantage. 25% Payment Adjustment Threshld (Display pages ): Since 2005, legislative and regulatry actin has delayed full applicatin f the 25% payment adjustment threshld fr mst LTCHs. This plicy will reduce LTCH payment amunts t the inpatient PPS amunt fr LTCHs that admit mre than 25% f Medicare cases frm an nsite r neighbring inpatient acute care hspital. Certain grandfathered LTCHs are permanently exempted frm the plicy by law. The 25% threshld plicy will be applied t site-neutral payment rate cases and standard payment LTCH cases. CMS is streamlining its regulatins regarding the 25 percent threshld plicy. CMS prpsed the plicy t apply t all cases discharged n r after Octber 1, Hwever, in rder t cmply with the full implementatin f the current 25% threshld plicy, CMS is revising the plicy t apply t all cases discharged n r after Octber 1, 2016 that ccur in cst reprting perids beginning n r after July 1, The streamlined versin includes: Rural LTCHs wuld be subject t a mre lenient 50% threshld; and Metrplitan Statistical Areadminant LTCHs wuld be subject t a threshld between 25 and 50%. All lcatins f an LTCH must be rural r lcated exclusively in an MSA-dminant area in rder t quality fr this special treatment; LTCH cases that were high-cst utliers in the prir hspital stay wuld nt be cunted in the numeratr, but they wuld be cunted in the denminatrs f an LTCH s cmpliance rate; and Medicare advantage cases wuld cntinue t be excluded frm the cmpliance calculatin. 2 P a g e

3 The rule finalizes a detailed plan fr payment reductins fr cases that exceed a 25% Rule threshld. The applicable percentage threshld wuld apply t the LTCH as a whle entity rather than independently f any ther lcatin f the LTCH. If an LTCH exceeds the applicable threshld during a cst reprting perid, payment wuld be adjusted fr discharges in excess f the threshld and discharges nt in excess wuld cntinue t be unaffected by the plicy. Rebasing f Market Basket DISPLAY pages CMS will revise and rebase the market basket used under the LTCH PPS (currently the 2009-based LTCH-specific market basket) t reflect a 2013 base year. LTCH Payment Rate DISPLAY pages , Incrprating the final updates and the effects f a budget neutrality adjustment, the table belw lists the full LTCH standard federal rate fr FFY 2017 cmpared t the rate currently in effect: Final FFY 2016 LTCH Standard Federal Rate $41, Final FFY 2017 $42, (prpsed at $42,314.31) Percent Change +1.7% (prpsed at +1.3%) The table belw prvides details f the final updates fr the LTCH standard federal rate fr FFY 2017: Final LTCH Rate Updates and Budget Neutrality Adjustments Marketbasket (MB) Update +2.8% (prpsed at +2.7%) Affrdable Care Act (ACA) - Mandated Prductivity MB Reductin ACA Pre-determined Reductin Wage Index Budget Neutrality Adjustment -0.3 percentage pints (prpsed at -0.5 percentage pints) percentage pints (prpsed at percentage pints) (prpsed at ) Overall Rate Change +1.7% (prpsed at +1.3%) Subclause II LTCH DISPLAY pages CMS is finalizing the revisin t the limitatin n the charges t beneficiaries plicy and related billing requirements fr subclause (II) LTCHs fr cst reprting perids beginning n r after Octber 1, The adjusted LTCH PPS payment t subclause (II) LTCHs under is cnsidered the full LTCH PPS payment (that is, the LTCH PPS standard Federal payment rate r site neutral payment rate, as applicable), and as such, under current plicy that payment applies t the LTCH s csts fr services furnished until the high-cst utlier threshld is met. CMS is revising that fr a subclause (II) LTCH, the Medicare payment wuld nly apply t the LTCH s csts incurred fr the days used t calculate the Medicare payment (that is, days fr which the patient has a benefit day available). 3 P a g e

4 Furthermre, in additin t the applicable Medicare deductible and cinsurance amunts, CMS is finalizing that the LTCH may nly charge the beneficiary fr services prvided during the stay that were nt the basis fr the adjusted LTCH PPS payment amunt. Therefre, subclause (II) LTCHs will be treated the same as IPPS-excluded hspitals paid under the Tax Equity and Fiscal Respnsibility Act f 1982 payment system t limit charges t beneficiaries and related billing requirements. Wage Index, Labr-Related Share, CBSA and COLA DISPLAY pages , There are n majr changes fr the calculatin f wage indexes fr LTCHs. As has been the case in prir years, CMS wuld use the mst recent inpatient hspital wage index: the FFY 2017 pre-rural flr and pre-reclassified hspital wage index, t adjust payment rates under the LTCH PPS fr FFY CMS did nt make any changes t the cst-f-living adjustments applicable t LTCHs in Alaska and Hawaii. The wage index, which is used t adjust payment fr differences in area wage levels, is applied t the prtin f the LTCH standard federal rate that CMS cnsiders t be labr-related. Fr FFY 2017, CMS is increasing the labr-related share frm 62.0% t 66.5% (prpsed at 66.6%). This change will prvide a decrease in payments t LTCHs with a wage index less than 1.0. On July 15, 2015, the Office f Management and Budget (OMB) issued revisins t three Cre-Based Statistical Areas that will be in effect fr FFY 2017 rulemaking: Garfield Cunty, OK was classified as gegraphically rural, nw qualifies as the new urban CBSA Enid, OK. The cunty f Bedfrd City, VA (SSA cde 49088) changed t twn status and became a part f Bedfrd Cunty (SSA cde 49090). It remains a part f CBSA Lynchburg, VA. The name f CBSA Macn, GA has been renamed as Macn-Bibb Cunty, GA. Updates t the MS-LTC-DRGs DISPLAY pages Each year, CMS updates the MS-LTC-DRG classificatins and relative weights. These updates are made t reflect changes in treatment patterns, technlgy, and any ther factrs that may change the relative use f hspital resurces. Althugh the DRGs used t classify patients under the LTCH PPS are identical t thse used under the inpatient PPS, the relative weights are different fr each setting. The MS LTC DRG relative weights are determined using nly data frm LTCH discharges that meet the criteria fr exclusin frm the site neutral payment rate (that is, LTCH PPS standard Federal payment rate cases). CMS will use its existing methdlgy t determine the MS-LTC-DRG relative weights. HCO Payments DISPLAY pages High cst utlier (HCO) payments were established under the LTCH PPS t prvide additinal payments fr very cstly cases. Outlier payments are made if the estimated cst f the case exceeds the payment fr the case plus a fixed-lss amunt. Csts are determined by multiplying the facility s verall cst-t-charge rati (CCR) by the allwable charges fr the case. When a case qualifies fr an utlier payment, CMS pays 80% f the difference between the estimated cst f the case and the fixed-lss amunt as a separate utlier payment, in additin t the traditinal DRG payment. CMS adpted tw separate high-cst utlier targets beginning in FFY 2016 ne fr LTCH PPS standard Federal payment rate cases and ne fr site neutral payment rate cases. Under the tw-tiered system, there is an 8.0% high-cst utlier target fr standard LTCH PPS cases using nly Standard LTCH cases. 4 P a g e

5 Fr site neutral cases, CMS uses a 5.1% target, the same as the perating IPPS target. CMS als uses the IPPS fixed lss amunt fr site neutral cases. Since CMS prjected that the current fixed-lss amunt wuld result in high-cst utlier payments that exceed the 8.0% target, CMS is finalizing the threshld fr cases paid under the LTCH standard Federal payment rate t increase frm $16,423 in FFY 2016 t $21,943 (prpsed at $22,728) in FFY The fixed-lss threshld fr cases paid under the site neutral payment rate will increase frm $22,538 in FFY 2016 t $23,570 (prpsed at $23,681) in FFY CMS will cntinue t make an additinal HCO payment fr the cst f an LTCH PPS standard Federal payment rate case that exceeds the HCO threshld amunt that is equal t 80 percent f the difference between the estimated cst f the case and the utlier threshld (the sum f the adjusted LTCH PPS standard Federal payment rate payment and the fixed-lss amunt fr LTCH PPS standard Federal payment rate cases f $21,943) fr bth LTCH Standard cases and site neutral cases. SSO Payments DISPLAY page 2264 Shrt-stay utlier (SSO) payments were established under the LTCH PPS t ensure that LTCH payments, which are predicated n lng lengths f stay (LOS), are nt applied t cases where the patient may have received nly partial treatment at a LTCH. If a patient is hspitalized fr less than 5/6 f the gemetric average length f stay fr a specific MS-LTC-DRG, but still incurs extrardinarily high csts, an LTCH discharge can qualify as an SSO case as well as an HCO case. CMS is finalizing that beginning FFY 2017, an SSO that is als an HCO case wuld receive an HCO payment f 80 percent f the difference between the estimated cst f the case and the utlier threshld. Updates t the LTCH Quality Reprting Prgram (LTCH QRP) DISPLAY pages Beginning in FFY 2014, the applicable annual update is reduced by tw percentage pints fr any LTCH that des nt meet the QRP requirements. The IMPACT Act f 2014 requires the specificatin f quality measures fr the LTCH QRP, including such areas as medicatin recnciliatin, skin integrity, functinal status, and incidence f majr falls. Als the IMPACT Act stipulates that measures must be standardized s they can be applied acrss pst-acute care settings. The fllwing table lists the LTCH QRP measures and applicable payment determinatin years. CMS is fcusing initially n measures that can achieve standardizatin acrss settings ver time, and minimize r avid duplicatin f existing assessment items. Measure NQF # Finalized Crss- Setting Measure Payment Determinatin Year NHSN Catheter-Assciated Urinary Tract Infectin (CAUTI) Outcme Measure NHSN Central Line-Assciated Bld Stream Infectin (CLABSI) Outcme Measure Percent f Residents r Patients with Pressure Ulcers That Are New r Wrsened (Shrt-Stay) Percent f Residents r Patients Wh Were Assessed and Apprpriately Given the Seasnal Influenza Vaccine (Shrt-Stay) #0138 FFY 2015 and beynd #0139 FFY 2015 and beynd #0678 Yes FFY 2018 and beynd #0680 FFY 2016 and beynd Influenza Vaccinatin Cverage amng Healthcare Persnnel #0431 FFY 2016 and 5 P a g e

6 beynd NHSN Facility-Wide Inpatient Hspital-Onset Methicillin-Resistant Staphylcccus aureus (MRSA) Bacteremia Outcme Measure NHSN Facility-Wide Inpatient Hspital-Onset Clstridium difficile Infectin (CDI) Outcme Measure All-cause Unplanned Readmissin Measure fr 30 Days Pst- Discharge frm Lng-Term Care Hspitals Percent f Residents Experiencing One r Mre Falls with Majr Injury (Lng-Stay) Percent f LTCH Patients with an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin Change in Mbility amng Patients Requiring Ventilatr Supprt #1716 FFY 2017 and beynd #1717 FFY 2017 and beynd #2512 Yes FFY 2018 and beynd #0674 Yes FFY 2018 and beynd #2631 Yes FFY 2018 and beynd #2632 FFY 2018 and beynd NHSN Ventilatr-Assciated Event (VAE) Outcme Measure N/A FFY 2018 and beynd T meet the requirements f the IMPACT Act, CMS is finalizing three new measures fr inclusin in the QRP. These three measures are all claims-based and crss-setting measures fr FFY 2018 payment determinatin and subsequent years. They are: Medicare Spend Per Beneficiary (MSPB); Discharge t Cmmunity (which assesses successful discharge t the cmmunity including n unplanned re-hspitalizatins and n deaths within 31 days fllwing discharge frm the LTCH), and Ptentially Preventable 30-Day Pst-Discharge Readmissins. A furth measure, ne that is assessment-based and is fr the FFY 2020 LTCH QRP, is a drug regimen review cnducted with fllw-up fr identified issues measure which assesses whether PAC prviders were respnsive t ptential r actual clinically significant medicatin issue(s). Data cllectin wuld begin April 1, CMS is finalizing its prpsal t add 4 new measures t LTCH QRP public reprting by the Fall f 2017 n Hspital Cmpare. CMS clarified the previusly finalized review and crrectin perids fr LTCH QRP public reprting and emphasizes its alignment with the Hspital IQR Prgram s plicies and prcedures. In the prpsed rule, CMS sught cmments n LTCH QRP quality measures under cnsideratin fr future years. These measures are: Transfer f health infrmatin and care preferences when an individual transitins; Patient Experience f Care; Percent f Patients with Mderate t Severe Pain; Advance Care Plan; Ventilatr Weaning (Liberatin) Rate; Cmpliance with Spntaneus Breathing Trial (SBT) (including Trachestmy Cllar Trial (TCT) r Cntinuus Psitive Airway Pressure (CPAP) Breathing Trial) by Day 2 f the LTCH Stay; Patients Wh Received an Antipsychtic Medicatin; and Venus Thrmbemblism Prphylaxis. Interim Final Rule DISPLAY pages Within the FFY 2017 IPPS/LTCH PPS final rule, CMS finalized an Interim Final Rule t implement sectin 231 f the Cnslidated Apprpriatins Act f 2016 that establishes a temprary exceptin fr certain wund care discharges frm the site-neutral payment rate fr certain LTCHs. In the rule, CMS establishes that rural LTCHs that participated in Medicare as an LTCH and was c-lcated with anther hspital as f September 30, 1995, that currently meets the requirements f sectin (f) f the Scial Security Act qualify fr the relief. Sectin (f) defines qualified LTCHs. 6 P a g e

7 This relief applies t patients wh received treatment in the LTCH fr severe wund cases and were discharged prir t January 1, Because the legislative criterin describing severe wunds des nt match ICD-10 guidelines, CMS is establishing unique definitins fr qualifying cases. The fllwing qualify as severe wund cases: wunds with mrbid besity, which are wunds in thse with mrbid besity that require cmplex, cntinuing care lcal wund care ccurring multiple times a day; and infected wunds, which require cmplex, cntinuing lcal wund care ccurring multiple times a day. CMS will use payer-nly cnditin cdes and LTCHs will have t flag these cases fr their Medicare Administrative Cntractrs t receive a cde n the claim, which will result in an LTCH PPS payment rather than a site neutral payment. The interim final rule als amends current regulatins t allw hspitals t reclassify based n their acquired rural status, effective with reclassificatins beginning with FFY This allws such hspitals t use the distance and average hurly wage criteria designated fr rural hspitals. In additin, a hspital that has an active Medicare Gegraphic Classificatin Review Bard (MGCRB) reclassificatin that is apprved fr a rural redesignatin will be allwed t maintain bth classificatins simultaneusly. Such hspitals wuld receive a reclassified urban wage index, and wuld als cntinue t be cnsidered rural fr all ther purpses. Hspitals reclassified in this way will be included in the calculatin f the state rural wage index, if including wage data fr hspitals with rural reclassificatins raises the state s rural flr. These hspitals will als be included in bth the wage index calculatin f their hme CBSA, as well as that fr the reclassificatin wage index f the MGCRB reclassified CBSA. Hwever, CMS states that these hspitals will be excluded frm the calculatin f a state s reclassified rural wage index. Hspitals with an existing MGCRB reclassificatin wuld als have the pprtunity t seek rural reclassificatin fr IPPS payment and ther purpses and keep their existing MGCRB reclassificatin. #### 7 P a g e