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Alberto Esquenazi, MD, and Thomas J. Smith, MBA

Upcoming Changes to the PM&R Landscape

In this episode of MossRehab Conversations, Alberto Esquenazi, MD, The John Otto Haas Chair of Physical Medicine and Rehabilitation and Chief Medical Officer at MossRehab, and Thomas J. Smith, MBA, Chief Operating Officer of MossRehab, discuss upcoming changes being implemented by CMS to post-acute care.

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Welcome to MossRehab Conversations, part of a continuing series of discussions with pioneers in physical medicine and rehabilitation from one of America's top rank rehab facilities. In this episode, Dr. Alberto Esquenazi, Chief Medical Officer and the John Otto Haas Chair of Physical Medicine and Rehabilitation at MossRehab. talks with Thomas J. Smith, Chief Operating Officer of MossRehab, about upcoming changes in the physical medicine and rehabilitation landscape and the potential programmatic shifts that would need to occur.

Dr. Esquenazi: Tom, I thought that this would be a good opportunity to talk a little bit about the upcoming changes that CMS is in some cases implemented in other proposing that will have great impact both in the care delivery that we provide at MossRehab and most importantly access to rehabilitation for patients and in need as a result of this pending changes. So I wanted to see, we could just chat about this and you who are probably one of the most educated individuals on all of this could help us understand them. And maybe we start by what are really the most upfront changes that will be occurring quite soon.

Thomas J. Smith: It's a pleasure to join you today. It appears that the more things change, the more they stay the same. And at the forefront these days, we have an industry coming out of, or still dealing with the pandemic, but constant change still occurring. Two items that come readily to mind the ongoing implementation of the impact act of 2014, which really is looking like it's headed towards the development of a unified post-acute payment delivery system. And another initiative coming out of CMS is this review choice demonstration project, which CMS is now proposing in an integrated way approval of all inpatient readmissions within certain states, Alabama starting, and then Pennsylvania coming, where all admissions will be reviewed for compliance and for medical necessity, CMS is kind enough to offer whether we wanna do this authorization prior to the patients coming in or after they are actually discharged from the institution, which is gonna have a significant impact to the inpatient rehabilitation providers, but also to upstream referral sources, including acute care facilities who are struggling with bed capacity.

Dr. Esquenazi: Thank you, Tom. So you talked about the post-acute integrated payment system. Maybe you could expand on that first and then we'll come back and talk about this demonstration project that it's being proposed. So, what does it mean to have a post-acute integrated payment system? What is it first of all, how would that impact what we do? Second? Why is Medicare attempting to do this

Thomas J. Smith: Great question! Thank you. So according to Medicare or CMS, there are four components of the post-acute sector that would include inpatient rehabilitation, long term, acute care facilities, skilled nursing facilities and home health. Over the years, these four sectors have been paid in different ways and they've assessed their patient in different ways. So it's very difficult for Medicare, particularly in these days of questioning the solvency of the program, whether they're getting value for the money being spent. And from CMS perspective, they believe that these sectors are serving the same types of patients. So it's very difficult for them to assess what is the best place of care for an individual at the right time in the person's recovery, given that there are different ways in which they're being paid and assessing those patients. So this impact act has been aimed at realigning, the post-acute sector, as I described and ensuring that we are all assessing the patients in the right way and not only upon admission, but upon discharge, they get an idea of functional in medical change for a patient. And at the same time moving towards being paid the same way. So then they can more accurately assess value based on amount paid and functional outcome.

Dr. Esquenazi: That's an important point, Tom. And I think something that you've mentioned in the past is that they use different outcome measure and so the different levels of care measure differently. And so I imagine that part of this would be to create some sort of a universal tool for assessment. And I think that would be a fantastic advantage for all providers. And certainly for patients to know that when we measure you seeing the same tool, we should be able to see the differentials. But I think that when you talk about a universal payment scheme, where they will pay the same across all providers, a few nuances are worth discussing. And that is that in inpatient rehabilitation facilities, we have very specific parameters that we have to follow in care delivery. And I'll use a simple one that is well known, which is the three hour rule in which we have to provide a minimum of three hours of care every day for patients that we are host in our facilities, but that's not true for other providers. So, home care doesn't have to do three hours of care. Nursing homes don't have to do that, and skilled care facilities don't have to do that. So how would that impact what we need to do and what CMS is trying to achieve?

Thomas J. Smith: The concept of us all speaking the same language sounds really good. And something that we all look forward to doing the process. And I think as you're alluding to is gonna be rather arduous. So as you had pointed out, there are different requirements for each level of care for an individual currently, as far as eligibility for people to access those services and continue stay, or an individual CMS will have to re-look at all of those eligibility criteria, medical necessity criteria, and probably have to do away with several and change many others to ensure that there's consistency across that post-acute continuum. The current standards in place are certainly prohibitive to moving forward as a sector of the healthcare industry towards this unified post-acute payment system.

Dr. Esquenazi: So Tom, if we could summarize the impact project is that it intends to really bring together or align all providers in post-acute care. And then hopefully come up with a, a strategy that will allow us to look out outcomes using an equivalent tool across all sites, and then come up with some payment scheme for that the payment scheme has not been formulated as such at least not yet that I'm aware of, but there was at one point the idea of a proposal to create a single site delivery care, where you could provide all of these levels of care that you spoke about by a single provider under a single license in a single location. Is that a viable option? Is that something that may make sense to do?

Thomas J. Smith: Certainly, from my perspective, it makes sense to do so. I think what Medicare's trying to do here is in addition to getting value for their dollars, maintain solvency of the program, that being Medicare, there have been other proposals on how to do this that have been made to Medicare for consideration. We have not heard back recently of those recommendations to provide as those levels of services all under one roof. I think there's great efficiencies to doing that, but again, would require changes in licensure regulations, eligibility criteria, and so forth.

Dr. Esquenazi: Thank you for that, Tom. So I'm gonna move over to discuss the demonstration project, which would require us, you in indicated some form of review for all patients cared for in an IRF. And you've mentioned briefly that Alabama would be where this project will start and then it'll move to Pennsylvania. And as I understand to a total of 17 states quickly after that, can you give us an overview of what is this demonstration project and what it is attempting to do.

Thomas J. Smith: For many years, CMS has stated that they are spending millions of dollars on inappropriate care across all sectors of the healthcare industry and accordingly they have most recently focused their attentions to that post-acute delivery system. So their take on this is to do a project that may demonstrate the efficacy of doing preadmission approvals or post discharge reviews of Medicare cases of committee into the acute inpatient rehab facilities to better determine that this missed billing is occurring in the inpatient rehab facilities world. Now, despite that there have been through various audit contractors, denials that have been given to providers for payments over the years that were eventually overturned. Many of which I think it's close to 90% of the, those denials have been overturned and actual payment has been given to providers after more thorough review. CMS is still thinking that this needs to get done to ensure that they are most appropriately spending taxpayer money on these types of services.

Dr. Esquenazi: Tom, from the post-acute care expenditures, which enumerates nursing homes and home care and inpatient rehabilitation facilities about what proportion of this expenditure is made in inpatient rehabilitation facilities.

Thomas J. Smith: So I think on an annual basis, it's about 6 billion worth of spending throughout the country. And those are big dollars. So any save dollars from a Medicare perspective would be money that can be reallocated for other use.

Dr. Esquenazi: It appears that really rehab is a small proportion of the whole post-acute care system.

Thomas J. Smith: Oh, absolutely. Absolutely. Yes.

Dr. Esquenazi: Why in a system of post-acute care delivery where rehab is the in from rehabilitation facilities have a small proportion of the overall expenditure. Why is the government looking at that?

Thomas J. Smith: So, I think we've been the focus of the federal government and trying to reduce expenditures in part because of the services that we provide and the way we get paid. From Medicare perspective for traditional fee for services, aid, discharge rate, it's very difficult to ascertain when during a stay was a patient's stay appropriate and then denied days. So the perspective here is a look at to these rather large numbers across a per discharge payment system.

Dr. Esquenazi: A final question that you could help us elucidate, and that has to do with the overall benefit of inpatient rehabilitation level of care to the population that we serve. And I think maybe your expertise, I know it'll be based primarily on MossRehab, but you understand the industry quite well. What else do you think we could to, first of all, continue to provide most cases, optimal care to this patient population, then how can we reduce or help CMS change its mind about this? What appears to be a fairly invasive procedure having to review every single case is not gonna be easy or inexpensive.

Thomas J. Smith: I think first and foremost, we have to, as an industry, make sure CMS is aware of the outcomes that our sector of the industry produce and compare those same outcomes to other sectors. So, when you look at very important outcomes, such as discharges to the community, which we do better than skilled nursing facilities and long-term acute care. When you talk about readmission, hospital readmissions being lower from inpatient rehabilitation, functional outcome gains are higher and inpatient rehab. I think that that needs to be taken consideration when there are proposed changes to payment, certainly payment always has to be looked at, but you really need to look at those outcomes to ensure the value you're getting for your dollar spent. And it's just not the MossRehab outcomes. It's just not our industry outcomes. There have been other associations who strongly endorse the use of acute medical inpatient rehabilitation after significant catastrophic injuries or illness such as cerebral vascular accidents or strokes, brain injuries, spinal cord injuries, and so forth. These are other stakeholders and an individual's health and wellbeing of our communities that are strongly advocating. That inpatient rehab is a required essential part of a recovery for many of the folks who are sustain those injuries or illness. So you have to look at both our industry outcomes, as well as what other stakeholders are saying as they're looking at their communities over a longitudinal perspective.

Dr. Esquenazi: Yeah, I think that's very important. In fact, we know recently both the American Heart Association Stroke Group and the Academy of Neurology, both made clear recommendations that post stroke, inpatient rehabilitation care is the best level of care for patients in early recovery. Post-stroke so yeah, I can see how that is of great value. Is there anything else you wish to add to this discussion that maybe I didn't, that you believe will be important for our listeners?

Thomas J. Smith: Yeah, so I think change is always a part of what we do. It's inevitable and we need to continue to try to enhance the services that we're providing for the people we are so privileged to serve. So we accept that as inpatient rehab providers, the, the need for continuous improvement and what I think we all need to advocate for is to be a part of that change, to be at the table, to discuss what our patients are like, what they're experiencing as well as others. So we can be a part of that continuous need for enhanced service to our community.

Dr. Esquenazi: Tom, I know that MossRehab is looking at ways to embrace as best as possible, some of these challenges. Knowing that MossRehab always says challenge accepted. You have set us up to succeed by implementing a process of standardization across our many areas of specialty care. So maybe you could share a little bit of that with us and why we are trying to standardize many of the actions that we do every day.

Thomas J. Smith: You know, MossRehab’s history of success. It's really attributed to our people. They have worked incredibly hard to help our patients, their fan members achieve the outcomes that they desire and return home. Our response to these changes is not going to be based on people working harder. It's really gonna be based that looking at our current processes in place, identifying opportunities for efficiencies or improvements so we can work smarter. We have very intelligent people, uh, that do tremendous work, but the focus here is really on our process to maximize the effort of our clinicians. So we have taken five different areas of the rehab admission. The rehab stays, if you will, with our patients, including the pre-admission, the patients, actual admission, their evaluation, their treatment, and their discharge planning, and started to look at inherent processes involved with each one of those and looking for ways to become more efficient and more effective in how we're providing care. And this initiative is not done by a bunch of administrators sitting around the table. It's been done through the collaboration with our frontline staff, with facilitation, from process experts, not necessarily experts in process of rehabilitation, but just at breaking down processes. So we can identify those opportunities and their efforts have been incredibly impactful. We have made significant information on getting better information to our treatment teams prior to admission, having equipment ready for the patient upon their arrival, as well as better preparing our patients for not only their admission here, but their eventual return to their community. So greatly indebted to our employees. Who've been a part of the process evaluation and how we deliver rehabilitative care.

Dr. Esquenazi: Tom, I always hear that many of the actions that we take here at MossRehab are because they improve our finances. And it always squeezes my heart a little bit to hear that because I know how hard we all work, not necessarily to deal with a financial issues, but really more focused on how do we deal with improving patient care. And if I hear you correctly, the idea of standardizing care or standardizing the processes for care better say is really about how we deliver better care in a smarter way. I think you use the word not working more or harder but working smarter. And I think that's what I hear you say with this standardization process. We are trying very hard for everybody to understand what is that they need to do and what we need to have in front of each one of us so that we can do it better.

Thomas J. Smith: Agreed.

Dr. Esquenazi: So, with that, I want to say, thank you. Thank you for all. You do. Thank you for being sure that MossRehab can continue its mission of excellence in rehabilitation care, excellence in education, research, and certainly in, and what you've done today is provide us with education so that we can better advocate for our patients and the field. Again, my thank you, Tom. Thank you, Albert.

That was Thomas J. Smith, Chief Operating Officer of MossRehab, in a leadership discussion with Dr. Alberto Esquenazi, MossRehab's Chief Medical Officer and the John Otto Haas Chair of Physical Medicine and Rehabilitation. Be sure to subscribe or check back at our website for other discussions with pioneers in physical medicine. I'm Bill Fantini. Thanks for joining us on MossRehab Conversations.