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June 15, 2018 D R A F T Ms. Seema VermaAdministrator Centers for Medicare & Medicaid Services Hubert H. Humphrey Building 200 Independence Avenue, S.W. Room 445-G Washington, DC 20201 File Code: CMS–1694–PRE: CMS-1694-P, Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2019 Rates; Proposed Rule Dear Ms. Verma: On behalf of its member hospitals, which includes approximately 20 long-term care hospitals (LTCHs), the Michigan Health & Hospital Association (MHA) appreciates this opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) regarding the proposed rule to update the LTCH Prospective Payment System (LTCH PPS) for fiscal year (FY) 2019. This proposed rule is estimated to increase Medicare fee-for-service payments to Michigan LTCHs by only $467,000, or by 0.3 percent, in FY 2019, significantly less than the projected 5.2 percent increase in medical cost inflation. This payment cut will further threaten the financial viability of Michigan LTCHs and their ability to provide care to Medicare beneficiaries and other patients. The MHA submitted separate comments regarding the CMS’ proposed changes to the hospital inpatient PPS (IPPS). The MHA’s primary concerns regarding the LTCH proposed rule include:Site-Neutral Cases and Duplicative Budget NeutralityShort-Stay Outlier PolicyQuality-Related Program ChangesPromoting interoperability by requiring it as a Medicare condition of participation25 Percent RuleThe MHA is appreciative of the CMS proposal to permanently withdraw the 25 percent rule particularly since implementation of the site-neutral payment policy mandated by the Bipartisan Budget Act of 2013 (BiBA). Site-Neutral Payments The Bipartisan Budget Act (BiBA) of 2013 established a site-neutral payment policy requiring that patients meet certain clinical requirements to be paid at the LTCH rate. LTCH cases that fail to meet specific criteria will be paid the lesser of the IPPS-comparable per-diem amount, plus any outlier payments, or 100 percent of these estimated cost of the case. The CMS implemented this policy on a rolling basis, starting with cost reporting periods that began on or after Oct. 1, 2015. For the first two cost reporting periods under the new system, site-neutral cases were paid a 50/50 blend of the LTCH PPS and site-neutral rates. The BiBA of 2018 extended the application of blended rates for LTCH site-neutral cases for two years to include cost reporting periods beginning in FY 2018 and FY 2019. To offset this extension, the legislation included a 4.6 percent reduction to the marketbasket update for site-neutral cases for FYs 2018 through 2026. While the proposed rule implements the BiBA provisions, it fails to provide details on the CMS’ timing, methodology or estimated impact of this cut. The MHA encourages the CMS to provide this detail to both the MAC and providers as soon as possible. UNDERPAYMENTS FOR SITE-NEUTRAL CASES DUE TO DUPLICATIVE BUDGET-NEUTRAL ADJUSTMENTS The CMS proposes to continue applying a 5.1 percent budget neutrality adjustment (BNA) to the site- neutral payment amount since it believes this is necessary to avoid increasing aggregate FY 2019 LTCH PPS payments, in comparison to what LTCHs would be paid if the payment system did not include a site neutral methodology. Since the IPPS rates used to pay site-neutral cases have already been reduced by 5.1 percent to ensure budget neutrality for IPPS outlier payments, applying this “second” 5.1 percent BNA within the LTCH payment system is duplicative and represents an unnecessary reduction to LTCH payments. We believe that the CMS decision to apply two BNAs is inappropriate and results in a material, unwarranted payment reduction to LTCH site-neutral cases. The MHA urges the CMS to withdraw the duplicative BNA.QUALITY-RELATED PROGRAM CHANGES The Affordable Care Act of 2010 mandated that reporting of quality measures for LTCHs begin no later than FY 2014. Failure to comply with LTCH quality reporting program (QRP) requirements will result in a 2 percentage point reduction to the LTCH’s annual marketbasket update. The CMS sends facilities written notifications of a decision of noncompliance with LTCH QRP requirements for a particular fiscal year, and notification of final decisions regarding any reconsideration requests. In addition to written notification, the CMS uses the Quality Improvement and Evaluation Assessment Submission and Processing (QIES ASAP) system to provide these notifications. The CMS proposes to expand the methods by which the agency would provide notifications to include at least one of the following:The QIES ASAP systemThe US postal serviceAn email from the Medicare Administrative Contractor (MAC).The CMS’ proposal is in response to provider input requesting additional methods of notification. While we are appreciative that the CMS is responding to provider concerns the MHA requests additional information regarding how providers should specify the recipients of email notifications from the MAC to ensure timely and effective communication with the appropriate LTCH staff member(s). The CMS proposes to remove two measures for the FY 2020 LTCH QRP and one measure from the FY 2021 program. The MHA is supportive of the proposed removal of the three measures from the LTCH QRP, in alignment with the CMS “Meaningful Measures” framework. REQUEST FOR INFORMATION ON INTEROPERABILITYIn the proposed rule, the CMS seeks input regarding whether the agency should promote interoperability by including electronic sharing of health information as a Medicare condition of participation for hospitals, skilled-nursing facilities, inpatient rehabilitation facilities, and other post-acute care settings. Although the MHA is supportive of the CMS’ promoting interoperability, we object to the CMS requiring interoperability as a Medicare condition of participation since this would likely result in some hospitals and post-acute providers no longer being eligible to participate in the Medicare program and therefore would be ineligible for Medicare payments for services to Medicare beneficiaries, potentially resulting in LTCH closures. Facility closures or exclusion from Medicare would reduce access to essential services for Medicare patients. The MHA recommends that the CMS provide additional incentive payments to help ensure that hospitals and post-acute care facilities have the resources necessary for investing in technologies that promote interoperability. SUMMARYThe MHA appreciates this opportunity to provide comments to the CMS regarding the proposed changes to the LTCH PPS. We believe our suggested modifications will result in positive changes for LTCHs and the Medicare beneficiaries they serve. If you have questions regarding our comments, please contact me at (517) 703-8608 or vkunz@.Sincerely,Vickie R. KunzSenior Director, Health Finance ................
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