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PAC PPS: Is the Continuing Care Hospital the Answer?

We recently wrote a blog about MedPAC’s initiative for a unified prospective payment system for PAC. The American Medical Rehabilitation Providers Association (AMRPA) has been instrumental in defining and supporting the “continuing care hospital” (CCH). AMRPA serves as a proactive advocacy group and unified voice. Its mission is to help guide changes to rehabilitation care legislation using a combination of data, experience, and common sense to ensure that quality patient-centered care remains the focus. On April 6, 2016, AMRPA wrote a letter to MedPAC in advance of the final meeting, commenting on PAC reform and the importance of the CCH model.

The Value of the Continuing Care Hospital

AMRPA describes the value of the CCH Concept as an “… opportunity to develop a patient-centered care model in which the ‘silos’ established by the variety of Medicare payment systems based on care setting are eliminated. Care under the CCH model is delivered based on need rather than setting, and there is an opportunity to realize cost savings due to efficiencies the CCH model would allow. Payment may also be more reflective of actual cost and resource use and not include the multiple costs associated with meeting the requirements of the current payment systems and transfers among care settings as is currently required.”

What could the CCH Model do for you?

The CCH model has done a solid job of defining principles and design that not only address the objectives of a unified PAC PPS but, more importantly, applies focus on the care delivery model and coordination of care based on patients’ needs. Time will tell if the CCH is the answer to help develop a unified PAC PPS. Now is the time to educate yourself on what a CCH model could offer. I think you will find that it is a well-thought-out and logical step in the right direction.

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PAC PPS: A Unified Payment System for All Post-Acute Care

If you follow what happens at the legislative level, you understand that there has been an ongoing effort to develop a unified payment system for post-acute care. The Medicare Payment Advisory Commission (MedPAC) met again on April 7, 2016, to discuss the recommendations for a unified post-acute care prospective payment system (PAC PPS).

The Approach to a Uniform PAC Payment System

According to the meeting brief, “Section 2(b)(1) of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 requires the Commission to develop a prototype prospective payment system (PPS) spanning the post-acute care (PAC) settings, using the uniform assessment data gathered previously during CMS’s Post-Acute Care Payment Reform Demonstration (PAC-PRD) (completed in 2011). The Act requires the Commission to submit a report by June 30, 2016, presenting an approach for a unified, cross-setting PAC payment system and, to the extent feasible, consider the impacts of moving to such a system.”

The brief indicates that this will serve as the final public meeting before MedPAC releases a mandated report by the June 30 date. The report will describe an approach for a consistent, cross-cutting PAC payment system as well as considerations of the payment impacts of moving to such a system.

The PAC PPS Plan

In a recent presentation, MedPAC Policy Analyst Carol Carter explained that the objective of implementing a PAC PPS is to change current policies–specifically, that of supporting four uniquely different, setting-specific payment systems as well as different payments for similar patients. Instead, MedPAC is seeking to develop a unified PAC PPS that would extend across the four settings and provide base payments on similar patient characteristics.
MedPAC’s recommended design for a PAC PPS includes:

• A common unit of service
• A common risk-adjustment methodology using patient characteristics
• An adjustment to HHA payments to align them to the costs of institutional stays
• Separate models to establish payments for non-therapy ancillary services (e.g., drugs) and routine and therapy services
• Two outlier payment policies: high-cost and short-stay
• No strong evidence for payment adjustments for rural providers or IRH/Us with teaching status

MedPAC’s staff noted that the IRF PPS teaching adjustment would be unnecessary, should the PAC PPS include a robust risk-adjustment methodology and a high-cost outlier policy to account for the higher costs of treating some patients.

For organizations that offer one or all of the PAC span internally, or for those that have relationships with external partners, it will be critical to understand how the unified PPS system will impact payments and just as important to understand how to continue to deliver true patient-centered care that is setting agnostic.

Mediware is committed to working with our partners to deliver information and tools to assist with ongoing PAC PPS. Learn more at

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Options for counting 10-visit-day progress reporting periods

It used to be that counting to 10 was a pretty simple activity. However, if you are an outpatient therapy provider, this has become considerably more complicated over the last couple years – especially as it relates to managing progress review periods. This effort calls for a form of new math to help providers stay on top of events.

To be clear, there are times when the math works out pretty simply. A patient is treated for 10 visit days, and on the last visit day, G-codes are submitted with a signed progress report document. This is the best case scenario and one we all hope happens more times than not.

But reality is not always as clear as that example. What if the patient, on visit-day 8, has an appointment with her referring physician before the next therapy, and the therapist wants to provide a summary to the referring doctor. In this case, it’s likely that the therapist will create a progress summary to give to the physician. This satisfies the progress summary requirement but leaves the G-code timeline out in the cold.

Providers can utilize some strategies to cope with what happens when the counts get out of sync.

One option is to disregard the progress summary that was created for the physician and do another on the 10th visit day to coincide with the G-code process. This keeps the counts in sync but poses an extra burden for the therapist, who incurs extra time documenting the patient status.

Another option is to submit the G-code early with the progress summary. CMS’ language isn’t exactly clear on whether this is the appropriate or desired action. It clearly meets the idea of “at least every 10 visit days” but it isn’t exactly “every 10 business days.” Different providers will have different policies on whether this is an appropriate interpretation of the rule.

A third option would be to submit the G-codes on schedule at the 10th visit day and not submit another progress summary until the next 10 visit days are complete (12 visit days later). This means that, on average, the progress summaries are being submitted every 10 days, but the time frame is a little flexible for any given progress summary. Again, different providers will have different ideas on whether or not this is a good idea.

Regardless of how your organization manages the 10–visit-day math problem, the goal remains to provide the best care for patients while not wasting time and money. Each of these approaches represents a different view of how best to remain compliant, competitive and efficient. One answer may not fit everyone. Your best bet is to pick one, be consistent and get good at managing it.

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