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3 Inpatient Rehabilitation Facility Care Use Before and After Implementation of the IRF Prospective Payment System Melinda Beeuwkes Buntin, Grace M. Carter, Orla Hayden, Carrie Hoverman, Susan M. Paddock, Barbara O. Wynn Supported by the Centers for Medicare and Medicaid Services
4 The analyses upon which this publication is based were performed under Contract C, entitled Inpatient Rehabilitation Facility Prospective Payment System Monitoring, Access, and Refinements, funded by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The contents of this publication do not necessarily reflect the views or policies of the Department of Health and Human Services, nor does the mention of trades names, commercial products, or organizations imply endorsement by the U.S. government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND s publications do not necessarily reflect the opinions of its research clients and sponsors. R is a registered trademark. A profile of RAND Health, abstracts of its publications, and ordering information can be found on the RAND Health home page at Copyright 2006 RAND Corporation All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from RAND. Published 2006 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA South Hayes Street, Arlington, VA North Craig Street, Suite 202, Pittsburgh, PA RAND URL: To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) ; Fax: (310) ;
5 iii Preface Since the inception of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) in 2002, the RAND Corporation has been contracted by the Centers for Medicare and Medicaid Services (CMS) to support its efforts to monitor the effect of the IRF PPS. To date, RAND has provided a number of analyses and reports on patient access to and utilization of IRF services before and after the implementation of the IRF PPS. Our reports address the Congressional mandate for a study of IRF patient access to care. This report focuses specifically on how the implementation of the IRF PPS has affected the characteristics and resource use of patients seen in IRFs and IRF practice patterns. This report was prepared for CMS, but should also be of interest to individuals in the health care and policy-making arenas who are concerned about Medicare beneficiaries' access to care. This work was sponsored by CMS under contract c. 1 Comments or inquiries should be sent to the first author of this report, Melinda Beeuwkes Buntin We would like to thank reviewers Dan Relles and Korbin Liu, and our project officer Jeanette Kranacs for helpful comments and suggestions. The research was conducted in RAND Health, a division of the RAND Corporation. A profile of RAND Health, abstracts of its publications, and ordering information can be found at 1 Findings from related research that has been sponsored under this contract are described in Beeuwkes Buntin et al. (2005); Carter and Paddock (2005); Paddock et al. (2005a); Paddock et al. (2005b); and Relles et al. (2005).
7 v Table of Contents Preface...iii Figures and Tables...vii Acronyms...ix Chapter I. Background and Executive Summary Payment System Changes Provider Responses to PPS Monitoring the IRF PPS IRF Utilization Patterns Unusual Cases Resource Use Limitations...9 Chapter II. Data Data Sources Sample Selection and Sample Size Chapter III: Overall Utilization Patterns Overview Methods Results Conclusions Chapter IV. Unusual Cases Very Short-Stay Discharges Interrupted Stays Short-Stay Transfers High Cost Outliers Discussion and Conclusions Chapter V. Resource Use Distribution of Length of Stay of IRF cases Changes in Resource Use by Types of IRF Payment-to-Cost Ratios in Conclusions Appendix 1: CMI Calculation References... 61
9 vii Figures and Tables Figures 3.1: Percent of IRF Cases by RIC, 1999 vs : Mean Motor Score by RIC, 1999 vs : Mean Cognitive Score by RIC, 1999 vs : Cumulative Distribution of All Cases in RIC 1 (Stroke) by CMG, 1999 vs : Comorbidity Tier Assignments for All Hospitals, for All Cases in 1999 and 2002, and for IRF PPS Cases in 2002: by Freestanding/Unit Status : Cumulative Distribution of LOS, by Year : Lengths of Stay in 1999 vs.2002, for Selected Large CMGs Tables 2.1: Number of Cases in Each Year in the Longitudinal Analyses : Counts of IRF PPS Discharges During CY 2002 Excluded from Sample and Remaining Sample, by Reason for Exclusion : Number of 1999 Bundled Discharges in Population and Sample with Case Mix Data, by Unit and Freestanding : Increases in the Volume of IRF Facilities and Bundled Discharges, (Excluding Maryland Hospitals) Versus Increases in the Fee-For-Service Discharges : Distribution of Cases Across RICs for All Cases in 1999 and 2002, and for IRF PPS Cases in 2002: by Freestanding/Unit Status : Mean Motor and Cognitive Scores for All Cases in 1999 and 2002, and for IRF PPS Cases : Percent of Cases by RIC in Each Comorbidity Tier: All Cases in 1999 and 2002, and for IRF PPS Cases in : Change in Case Mix Index (CMI) Between 1999 and : Percent of Cases in Each Demographic Category by Year for the Sample, 1999 and : Very Short-Stay Cases Discharged Alive by Length of Stay : Distribution of Interrupted Stays: : Distribution of Interrupted Stays by Hospital Characteristics : 2002 Bundled Stays by Hospital Characteristics : Changes in Transfers Measured by Post-IRF Status : Transfers by Discharge Destination : Simulated IRF PPS Payments for All 2002 Bills Assuming 100percent Federal Rate by Hospital Characteristics : Simulated IRF PPS Payments for All 2002 Bills Assuming 100percent Federal Rate by RIC and Comorbidity Tier : Mean LOS of Bundled Discharges Declined Each Year Between 1998 and 2002 and Recently Declined More in Freestanding Facilities Than in Units, Although LOS Within Most RICs Remains Higher in Freestanding Facilities... 46
10 viii 5.2: Mean Length of Stay Declined Between 1999 and 2002 in Almost All RICs and Typically Declined More in Freestanding Facilities Than in Units, Although LOS Within Most RICs Remains Higher in Freestanding Facilities : Comparison of Volume, Cost, and LOS for 1999 and 2002 for the IRF Population, by Provider Characteristics : Comparison of LOS, Percentage of Costs for Therapy, and Average Daily Therapy Cost for 1999 and 2002, by Provider Characteristics : PPS Payment, Average Case Weight, Cost and Payment-to-Cost Ratios for All 2002 Cases, by Hospital Characteristics : Average Standardized Cost in 2002 Was Highly Correlated Across Tier and RIC with Case Weight and Federal Payment, But Variations in the Payment-to-Cost Ratio Show the Need To Refine the CMGs and Tiers... 57
11 ix Acronyms CMG CMI DSH HHA IME IRF IRF PAI IRF PPS LOS MDS PTC RIC SNF Case mix group Case mix index Disproportionate share Home Health Agency Indirect Medical Education Inpatient Rehabilitation Facility Inpatient Rehabilitation Facility Patient Assessment Instrument Inpatient Rehabilitation Facility Prospective Payment System Length of stay Minimum Data Set Payment-to-cost Rehabilitation Impairment Category Skilled Nursing Facility
13 1 Chapter I. Background and Executive Summary The Medicare program began to phase in the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) on January 1, IRFs are specialized hospitals or hospital units that provide intensive rehabilitation (generally three or more hours a day of therapy) in an inpatient setting. Under the IRF PPS, Medicare pays facilities a predetermined rate per discharge that varies by case mix group (CMG). The CMG depends on the patient s age, impairment, functional status (motor and cognitive) at admission, and comorbidities. In addition, facilities receive special rates for patients who die in the hospital, short-stay transfer patients, atypically short-stay patients, and high cost outliers. The rate also varies across facilities based on area wages, the share of a facility s patients that are low income, and rural location. Previously, inpatient rehabilitation facilities were paid using a historical cost-based system. The shift from cost-based to prospective payment gives facilities incentives to provide care efficiently, since they can keep any difference between the prospectively set payment amounts and their costs. However, it also gives facilities incentives to change their care and practice patterns in other ways and to change their coding practices to increase revenue. Changes could take the form of adjustments to the way patients are assessed and their diagnoses and functional status are coded, changes in treatment intensity and length of stay, changes in transfer policies, and changes in admissions policies. In addition, some changes coinciding with the new PPS could be due to other Medicare rules or other changes taking place in the health care system. These changes, no matter what their cause, could have adverse or beneficial effects on patients and/or cause unwarranted increases in Medicare expenditures. In this chapter we describe changes in incentives due to the implementation of the prospective payment system, and then briefly summarize the work presented in detail in the following chapters on monitoring use of IRF care. Two related project reports describe changes in the use of post-acute care generally and probe whether there are real changes in the severity of patients seen in IRFs (Beeuwkes Buntin et al., 2005; Carter G and Paddock SM, 2005).
14 2 1.1 Payment System Changes Before looking at the results of monitoring IRFs responses to the IRF PPS, it is important to understand how the payment system works and particularly the incentives provided by the payment system. The Balanced Budget Act of 1997, as amended by the Balanced Budget Refinement Act of 1999 and the Benefits Improvement Act of 2000 provided for a per discharge PPS. IRFs began to be paid under the prospective payment system on the first day of their fiscal year following January 1, Thus, some facilities fell under the system immediately, while the payment system was effective for others as late as December Regardless of fiscal year, however, IRFs were required to submit patient assessment forms beginning on January 1, The IRF PPS payment system assigns cases to CMGs in order to establish payment amounts. Each CMG has a relative weight reflecting the average cost per case for Medicare patients assigned to the CMG relative to the average cost per case for all Medicare patients receiving IRF care. To determine payment, the standard rate (adjusted for the IRF s geographic location and proportion of low-income patients) is multiplied by the CMG relative weight. Payments are increased by an outlier supplement for very expensive cases. Also, short-stay transfer cases are paid on a per diem basis, where the amount of the per diem depends on CMG. The data used to assign CMGs to each IRF patient come from the IRF Patient Assessment Instrument (PAI). In order to assign a CMG, each case is first classified into one of 21 Rehabilitation Impairment Categories (RICs). Most RICs are based on particular body structures and/or causes of impairment. Each RIC is subdivided into CMGs based on functional independence and age. Functional independence is determined by the response to 17 questions on the IRF PAI. The sum of 12 items is used to create a motor score, and the remaining five items are summed for a cognitive score. The values of motor and cognitive scores and patient age determine the patient s CMG assignment within RIC. The CMG assignment rules were derived in order to maximize the ability to predict cost under the constraint that payment for care of a patient with a lower score (less independence) is never less than for care of an otherwise similar patient with a higher score.
15 3 Comorbidities are used to split most CMGs into four payment subgroups: three comorbidity tiers and a subgroup with no relevant comorbidity. Comorbidity tier affects the relative weight used for payment in the CMGs. Tier 1 comorbidities are the most costly and have the highest relative weight within the CMG followed in order by tiers 2 and 3. The least expensive subgroup, which is the one with the lowest weight within each CMG, consists of patients with no relevant comorbidity. Patients that have comorbidities in more than one tier are assigned to the most expensive of those tiers. Multiple comorbidities in the same or lower tiers do not affect payment. Payment CMGs are calculated during bill processing and depend on the discharge destination shown on the bill, the length of stay, and the admission CMG previously assigned. The payment CMG is the same as the admission CMG for cases with a stay more than three days in the hospital and who are discharged alive. Transfer cases who stay 3 or fewer days also remain in the admission CMG. Non-transfer cases who stay 3 or fewer days and cases who die in the hospital are assigned to one of 5 special payment CMGs. One goal of the IRF PPS is to enhance access to IRF care by compensating IRFs based on their case mix. Prior to the IRF PPS, payment for inpatient rehabilitation care for Medicare beneficiaries had been made under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 (as amended by subsequent legislation). TEFRA capped per discharge payments to an inpatient rehabilitation facility at a facility-specific maximum that was determined using the IRF s base year of operation from which facility-specific costs were estimated. Under TEFRA, there was no adjustment to payments due to changes in a hospital s case mix the base year. Updates to the rates did not keep up with inflation, thus allowing new hospitals to obtain larger payments than existing hospitals. The lack of case mix adjustment under TEFRA created incentives for providers to preferentially admit relatively less expensive cases, thus raising concerns that TEFRA limited beneficiary access. The IRF PPS was expected to enhance access by providing greater levels of reimbursement for those with greater clinical needs (Stineman, 2002). Another goal of the IRF PPS is to control Medicare s inpatient rehabilitation expenditures. Cases who did not fulfill an entire course of rehabilitation, such as short stays and transfers, were fully compensated under TEFRA. IRFs took advantage of
16 4 incentives under TEFRA to maximize payment. This led to increased utilization and cost during the base year(s), as well as afterward, relative to pre-tefra years, thus resulting in increased expenditures for the Medicare program (Chan et al., 1997). By 1995, payments exceeded costs by 7 percent in freestanding rehabilitation facilities and 4 percent in rehabilitation units (MedPAC, 1998). 1.2 Provider Responses to PPS The implementation of prospective payment can trigger a range of effects among providers (Ellis and McGuire, 1996). Providers can succumb to stinting on the amount of care delivered, for example by reducing therapy intensity. Providers can engage in selection behavior, such as changing their admission policies so as to restrict access for patients not likely to be profitable and increase admission rates for patients who are likely to be profitable. Providers can alter their coding practices for patient functional status in order to increase payments without changing their case mix; this coding could occur in the form of deliberate upcoding or in response to changes in coding instructions, better training of coding staff, and incentives under the new payment system to thoroughly code patients limitations. On the positive side, providers might respond to prospective payment by becoming more efficient and produce equivalent health outcomes with fewer inputs. Providers who experienced fiscal pressure under the former payment system might be able to admit patients who are more medically complex or who have lower functional status than before. Provider responses to prospective payment across a variety of care settings have been documented that highlight the potential for stinting. In a large, nationally representative sample of Medicare beneficiaries from 297 hospitals, Kahn et al. (1992) found that the length of stay (LOS) after implementation of the PPS for acute care hospital inpatient services dropped significantly for all of the conditions studied despite patients being sicker at admission post-pps versus pre-pps and that there was greater instability among patients at discharge following implementation of the PPS. Neu and Harrison (1988) found that this observed decrease in the average length of an acute care stay was accompanied by increases in Skilled Nursing Facility (SNF) and Home Health Agency (HHA) utilization following an acute care stay, indicating the potential for a shift of care that had been previously provided by the acute care hospital to other settings. The
17 5 effect of the Balanced Budget Act (BBA) of 1997 on post-acute care has also been examined. Angelelli et al. (2002) found that the lengths of stay and readmission rates of the costliest, most medically complex patients discharged to nursing facilities in Ohio post-bba versus pre-bba were quite steady over time, while Yip et al. (2002) found decreases in the intensity and duration of physical and occupational therapies among Medicare beneficiaries in three southern California SNFs. White (2003) similarly concluded that the proportion of patients in freestanding SNFs receiving high levels of therapy declined after the SNF PPS was implemented. Selection behavior effects have been found as well. In a small sample of Medicare beneficiaries in three southern California SNFs following implementation of the SNF PPS, Yip et al. (2002) found that patients admitted post-pps had conditions with better-defined (i.e., more predictable) care protocols, though patients had worse scores on health-related quality of life and functional status but better scores on emotional health. Newhouse (1989) found that acute PPS discharges for which the payment was relatively less generous increasingly were admitted to last resort public hospitals under the acute PPS. Coding change has been identified under prospective payment implementation. One-half of the increase in the case mix index of Medicare patients at acute care hospitals in FYs 1987 and 1988 was attributed to changes in coding and administrative practices, resulting in increased Medicare expenditures (Carter, Newhouse, and Relles, 1991). Coding changes were expected following the IRF PPS since providers did not previously have an incentive to thoroughly code patient comorbidities; comorbidities garner additional payment under the IRF PPS that did not exist under the TEFRA system. The IRF PAI used under the IRF PPS to collect patient admission and discharge information on functional status, was slightly modified from the FIM Instrument (Uniform Data System for Medical Rehabilitation, 1997) that was used prior to the IRF PPS, which could also cause coding change. 1.3 Monitoring the IRF PPS The goals of the IRF PPS and the theoretical and observed effects of prospective payment led to the analyses described in this report. It focuses on two areas: changes in beneficiary access to and use of IRF care and responses to specific incentives created by
18 6 the payment system. In monitoring access to care it is important to describe trends in the use of IRF care, monitor the types of beneficiaries accessing IRF care, and look for evidence that payment changes affect beneficiary access to IRFs. As mentioned above, the shift from cost-based to prospective payment gives facilities incentives to provide care efficiently, since they can keep any difference between the prospectively set payment amounts and their costs. However, it also gives facilities incentives to selectively treat patients who are expected to have below-average costs within a payment category and to change their coding practices. It was important to monitor, therefore, IRF changes in utilization patterns, responses to special payments for atypical patients, resource use in IRFs, and coding changes. This report also addresses the Congressional mandate for a study of IRF patient access to care. 1.4 IRF Utilization Patterns Patterns of utilization within IRFs were examined for evidence of changes. Patterns in IRF care observed in the analysis of 2002 data were largely consistent with the incentives created by the IRF PPS and with trends previously observed from 1996 through There was an increase in the number of IRFs caring for Medicare patients and a larger increase in the number of Medicare beneficiaries seen in IRFs between 1999 and 2002 in both absolute terms and on a per eligible beneficiary basis. There was also a shift in the composition and/or coding of patients seen in IRFs after the implementation of the IRF PPS. A greater proportion of patients were coded as having comorbidities and motor and cognitive functioning scores declined. 2 More details can be found in Chapter 3 of this report. 1.5 Unusual Cases Specific types of patients with atypical stays were examined to see if prospective payment might shift patients across sites. Under the IRF PPS, typical cases are defined as those who stay more than 3 days, receive a full course of inpatient rehabilitation, and are discharged to the community. Special payment rules apply to most unusual cases who deviate from this pattern. There are anticipated behavioral changes in response to these rules that might occur under the IRF PPS if an IRF tries to maximize net revenue. The 2 Patients are coded into tiers based on their comorbidities. Tier 1 is the most expensive tier. A greater ability to function independently is captured in higher functioning scores.
19 7 incentives are specific to the payment policies for unusual cases and may interact with other incentives to reduce costs and increase revenues. For the most part, IRF facilities responded in anticipated ways to the financial incentives created by the various policies for very short-stay cases and interrupted stays. 3 In particular, there is evidence of: A reduction in non-transfer stays lasting fewer than 3 days and an increase in nontransfer stays lasting 4-5 days. The proportion of non-transfer cases considered very short-stay cases declined about 10 percent. A reduction in the proportion of interrupted stays lasting fewer than 3 days and an increase in the proportion lasting 4-5 days. A substantial increase in short-stay transfers that was largely offset by a decline in longer stay transfers so that there was only a small increase in the overall transfer rate. We assume that the increase in short-stay transfer rates largely reflects the overall trend toward shorter stays. There was an increase in the transfer rates to acute care hospitals but an unexpected decline in transfer rates to SNFs and nursing homes. Freestanding hospitals showed stronger behavioral responses than units to the incentives created by the payment policies for very short stays and interrupted stays. For interrupted stays, the payment-to-cost ratio for freestanding hospitals was 1.00 compared to 0.88 for units of acute care hospitals. Overall, outlier payments were 3.0 percent of total payments, which was the percentage offset used to establish the initial outlier threshold. Consistent with having lower costs per discharge, freestanding hospitals received 1.2 percent of total payments as outlier payments compared to 4.0 percent for units of acute care hospitals. More details can be found in Chapter 4 of this report. 1.6 Resource Use Also mentioned above, providers can respond to prospective payment by becoming more efficient and/or by stinting on care since they can keep differences 3 A per diem rate applies to a short-stay transfer--a patient with a length of stay that is less than the mean length of stay for the CMG minus 0.5 days who is transferred to another IRF, an acute care hospital, a long-term care hospital, or a Medicare or Medicaid-certified nursing home. Long-stay transfers are paid as a typical case. One CMG payment is made for an interrupted stay, which occurs when a patient is discharged and returns to the same IRF within 3 consecutive calendar days. Precise estimates of changes in transfer rates, and therefore also of atypically short-stay cases, are problematic because of inconsistencies in the definitions used to report transfers and the under-reporting of short-stay cases in the 1999 baseline data.
20 8 between payments and costs as profit. These changes can be manifest in changes in resource use including changes in IRF LOS, costs (including therapy costs), and payment-to-cost ratios. Length of stay in IRFs has been declining at least since There was a particularly large decline in the number of cases with extremely long LOS and an increase in the percentage of cases in most payment groups discharged at the average LOS. The rate of decline increased throughout this period and average LOS declined 5.8 percent from 2001 to 2002, the first year of the PPS. Average LOS declined within each RIC between 1999 and 2002, the two years for which case mix data were available. The rate of decline in LOS varied across groups of hospitals. In general, hospitals that had a relatively long LOS in 1999 had greater percentage declines between 1999 and 2002, thus increasing the uniformity of IRF LOS across the country and across types of hospitals. The average cost per case increased 1.6 percent between 1999 and Since LOS declined by 13 percent over this period, the cost per day increased by 16.6 percent. This exceeds the three-year rate of increase in the hospital market basket of 10.9 percent. Therapy costs per day increased at a lower rate (10.6 percent) than other costs in the same period, thus decreasing the percentage of costs devoted to therapy from 24.4 percent to 23.2 percent. The rate of change in average case costs, daily costs, and payment-to-cost ratios varied across groups of hospitals. In 1999, freestanding cases cost on average $187 more than units but in 2002 they cost $105 less. If all hospitals had been paid based on 100 percent of the PPS rates throughout all of 2002, PPS payments during 2002 would have been 14 percent higher than cost. This is due to the lack of cost growth per case since 1999, the increase in the payment rate by the CMS actuary to account for payment trends under TEFRA, and changes in coding. Payment- to-cost (PTC) ratios varied across groups of hospitals, with freestanding and proprietary hospitals having PTCs of In contrast, units had a PTC ratio of only Despite the fact that freestanding hospitals had lower costs in 2002 than units, they had longer average LOS. Therefore, it remains possible that the PTC ratio of units was affected in part by accounting practices left over from the TEFRA era; TEFRA cost-based payments were determined through a
21 9 cost allocation process and hospitals had an incentive to shift costs from their acute care services, paid under the acute prospective payment system, to the rehabilitation units. The PTC ratios for other groups of IRFs show the effectiveness of the payment adjustments, with only small variations between rural and urban areas, and by lowincome patient, or disproportionate share (DSH), categories. Although payment largely followed costs by RIC and tier, variations in the PTC ratio across these categories show the need to refine the payment parameters of the PPS. There also was a positive correlation between PTC ratio and hospital Case Mix Index (CMI) quartile. In addition to demonstrating that the current weights are inappropriate for the coding practices prevalent in 2002, this may indicate that coding practices varied across hospitals with those in the highest CMI quartile responding most completely to the PPS incentives, or even upcoding. More details can be found in Chapter 5 of this report. 1.7 Limitations It is important that all of the changes associated with the shift to the IRF PPS be studied in the context of changes in overall patient care use, costs and outcomes. For example, declines in lengths of stay may indicate increases in treatment efficiency if patient outcomes remain steady. Similarly, increases in payments to IRFs could theoretically be offset by decreases in the use of other types of care, such as home health care, following discharge from IRFs. In addition, it should be noted that these analyses reflect the latest data available, but that they cover only the early stages of the IRF PPS implementation. Therefore, it is important to continuously monitor the impact of the implementation of the IRF PPS as additional data, including data on Medicare costs and outcomes, become available.
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Rehabilitation Regulatory Compliance Risks Christine Bachrach Vice President & Chief Compliance Officer University of Maryland Medical System 2011 AHIA Annual Conference Agenda - Rehabilitation Compliance
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Glenn M. Hackbarth, J.D. 64275 Hunnell Road Bend, OR 97701 Dear Mr.Hackbarth: The Medicare Payment Advisory Commission (MedPAC) will vote next week on payment recommendations for fiscal year (FY) 2014.
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issue brief April 20, 2011 Medicaid: A Key Source of Insurance in New Hampshire As state and federal policymakers come to grips with substantial budget shortfalls both now and into the future one public
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June 24, 2015 Andrew Slavitt Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services Attention: CMS- 1629-P, Mail Stop C4-26-05 7500 Security Boulevard Baltimore, MD 21244-1850
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Executive White Paper Series April 2015 In Cooperation With: This white paper series is produced by the LINK Conference, whose mission is to accelerate productivity and innovation in long term care and