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Comment Letter to CMS: Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2023 and Updates to the IRF Quality Reporting Program

May 31, 2022

The Honorable Chiquita Brooks-LaSure
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-1767-P
P.O. Box 8016
Baltimore, MD  21244-8016

RE:  Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2023 and Updates to the IRF Quality Reporting Program (CMS-1767-P)

Dear Administrator Brooks-LaSure:

On behalf of The Hospital and Healthsystem Association of Pennsylvania (HAP), which represents approximately 235 member hospitals and health systems, including nearly 70 inpatient rehabilitation facilities and units, we appreciate this opportunity to comment about the Centers for Medicare & Medicaid Services’ (CMS) fiscal year (FY) 2023 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) proposed rule. We appreciate CMS’ streamlined approach to the rule, which allows providers to focus on spending time with patients. With recognition that several of the changes proposed in this year’s IRF PPS proposed rule reflect the stakeholder input gathered in previous comment periods, we submit the following comments to not only inform the FY 2023 IRF PPS Final Rule but also direct future policy efforts.

We will focus our feedback on two requests for information—changes to the IRF transfer policy and requiring IRF-PAI collection for all patients.

Feedback on expanding the current IRF transfer policy to include discharges to home health

HAP appreciates that CMS is seeking stakeholder input on the IRF transfer policy as it considers whether changes to the policy are needed. This policy, originally intended to disincentivize early discharges from IRFs, currently applies to stays with a less than average length-of-stay for cases which are transferred directly to another IRF, general acute-care hospital, or nursing home/skilled nursing facility (SNF). Reflecting recommendations outlined in a December 2021 report by the Department of Health and Human Services Office of the Inspector General, CMS is proposing to incorporate a “discharge to home health” element in the IRF transfer policy in the future, aligning with inpatient and inpatient psychiatric facility payment policies and generating Medicare savings.

Across the commonwealth, Pennsylvania’s IRFs help patients recover from debilitating illness or injury and regain physical independence. IRFs partner with IRF patients and their families is to get the patient back to their homes and communities as quickly as possible. While the goal is the same from every IRF patient, Pennsylania IRFs treat a wide mix patients, many of whom also suffer from the effects of chronic conditions, such as diabetes, heart disease, or chronic obstructive pulmonary disorder. The ideal discharge goal for IRF patients is to be safely discharged to their homes and communities but the supports needed to ensure a successful discharge vary.

HAP believes that home health is an important and necessary continuation of care for many IRF patients. As CMS considers whether discharges to home health are a “substitution of care” versus “an extension of the normal progression for inpatient rehabilitation care,” the current IRF PPS transfer policy is working effectively and should not be modified to include home health care. An expansion of the IRF transfer policy decrease patient access to home health—particularly for the complex patients treated by our member hospitals. Given the elevated importance of home-based services since the beginning of the COVID-19 pandemic, CMS should consider the advisability of policy changes that may present obstacles for patients seeking care in the home.

Feedback on the proposal to require IRF-PAI collection for all patients, no matter the payor

CMS proposes to require IRFs to report quality data, including the standardized patient assessment data in the IRF Patient Assessment Instrument (PAI), on all patients regardless of payor. The proposal revisits all-payor IRF-PAI collection proposed but not finalized in the FY 2020 IRF PPS proposed rule. In this proposed rule, CMS proposes to begin collecting IRF-PAI assessments on all patients receiving care within an IRF, regardless of the patient’s payor. Public posting would begin with the FY 2025 IRF QRP and the underlying data collection is proposed to begin on October 1, 2023. If finalized, IRFs would be required to collect the IRF PAI for all patients beginning October 1, 2023. The agency estimates that the increased burden will result in an additional average cost of $28,505.41 per IRF annually.

HAP generally supports standardized data collection and quality improvement initiatives; however, we cannot support this proposal without additional information about CMS’ implementation approach. While some Pennsylvania IRFs either already complete an IRF-PAI on all patients or are prepared to commence collection, the increased administrative burden is significant, particularly as IRFs continue to deal with lingering COVID-19 pandemic impacts, specifically with respect to nurse staffing and workforce shortages and infection control/mitigation efforts. These impacts are unlikely to resolve by October 2023.

HAP encourages CMS to reduce the 95 percent completion threshold as part of any future implementation approach in order to bring the IRF patient assessment tool completion threshold in line with that of other post-acute care settings (SNFs and LTCHs). Any efforts to better align reporting across the post-acute quality reporting programs also should involve the adjustment of the compliance thresholds to match across settings.

HAP appreciates the steps that CMS is taking to solicit feedback from stakeholders and reduce cumbersome and duplicative regulatory burdens. We look forward to working with you and to continuing to make progress to improve our health care system for our hospitals and health care systems and our patients, their families, and the communities that we serve.

Thank you for the opportunity to submit our comments on the FY 2023 IRF PPS Proposed Rule.

If you have any questions, you are welcome to contact me at (215) 575-3741.


Jennifer Jordan
Vice President, Regulatory Advocacy



Topics: Federal Advocacy, Medicare

Revision Date: 5/31/2022

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