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Brady Faces Demands from Groups on Rehabilitation Pay Bill

By Kerry Young, CQ Roll Call

September 16, 2016 -- A coalition of groups representing nursing and rehabilitation centers on Thursday pressed House Ways and Means Chairman Kevin Brady for significant changes in his proposal to peg more Medicare payments to judgments about the quality of service provided.

The Texas Republican last week held a hearing that included discussion of his bill (HR 3298), which seeks to move post-hospital care more toward value-based purchasing. The bill would require the Centers for Medicare and Medicaid Services (CMS) to establish performance standards and scores by which to rank providers. Payments would be partially based on these rankings.

Nursing center industry groups including the American Health Care Association and Leading Age want revisions in Brady's draft. In its current version, the bill leans too much on metrics based on how medical resources are used, said the signers of the five-page letter, which also include the National Association for Home Care & Hospice.

Instead, the coalition wants to delay the shift toward a new system to wait until metrics based on patients' outcomes will be ready. CMS is already working on such measurements but will not finish for years. The group also wants nursing centers to be able to receive bonus payments for improving their quality scores.

"Should these revisions be made, we will be better able to achieve support from our respective memberships," the groups said in their letter. "If these changes are not made, we will be left with no choice but to oppose the legislation."

Brady is one of the congressional leaders in efforts to update how Medicare pays for care of people recovering from strokes, serious illnesses and surgeries. Known as post-acute or post-hospital care, this field costs Medicare about $60 billion a year. Brady helped with the passage of the IMPACT Act of 2014 (PL 113-185), which calls for CMS to establish a framework for a new payment approach to all post-acute care. The agency now issues separate rules for payments for skilled nursing facilities, inpatient rehabilitation centers, specialty hospitals and home health agencies that help people recover.

"We strongly urge that changes be made to H.R. 3298 so that it adheres to the IMPACT Act’s implementation timeline, thereby ensuring that the cross-setting measures that would be necessary for implementing this legislation have been fully developed, validated and vetted," the groups said in their letter.

But experts have raised questions about the slow rollout of changes envisioned by the IMPACT Act. A member of the Medicare Payment Advisory Commission (MedPAC) at a March meeting wondered whether the timeline for changes to this field could be accelerated. The deadlines now in place would transition to a more unified payment system around 2026 or 2027, said MedPAC commissioner Kathy Buto, a veteran federal health adviser. "We're talking 10 years before there will be anything new," she said.

'Breathtaking' Change

Yet people who work in the field of post-acute care argue that they already feel the effects of a whirlwind effort within CMS to revamp how the federal government pays for health care.

"The level of change and innovation to achieve this goal is unprecedented," Gregory M. Worsowicz, a doctor speaking on behalf of the American Academy of Physical Medicine and Rehabilitation, told the House Ways and Means Health Subcommittee at a Sept. 7 hearing.

He, too, asked that Congress hold off on efforts to create a value-based purchasing program for post-hospital care, saying that both work in the field and CMS initiatives will have a broad effect on the practice of medicine. CMS, for example, has a test underway that can reward or dock hospital reimbursements based on how well people enrolled in Medicare fare in the 90 days following hip and knee replacements. As a result, hospital officials are taking a new look at the post-acute care options for their patients.

"We believe passage of this legislation at this time would add major additional policy changes to a sector that is struggling to comply with the existing pace of reform," Worsowicz said of Brady's bill said in testimony.

The IMPACT Act's timeline is meant to allow CMS to gather good comparison data about the different options for post-acute care, he said. He considered the pace of the work that CMS already is doing to roll out quality measures "breathtaking."

"It presents significant challenges for providers in keeping abreast of, and adapting to, these changes which are primarily focused on quality improvement," Worsowicz said.

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