The trusted source for
healthcare information and
Town Hall meeting fails to sway CMS
75% rule continues to frustrate providers
Officials with the Centers for Medicare and Medicaid Services (CMS) were surprised at the number of people who participated in the town hall meeting held May 19 in Baltimore to allow comment on the 75% rule. But they weren’t all that surprised at the message that came from the rehab field.
Tom Barker, special assistant to the administrator, says he heard a couple of new ideas but that the testimony from the nearly 300 people who attended the meeting mostly confirmed what
he already believed about the problem. Another 700 listened in by conference call, making it the largest town hall meeting in CMS history.
Much of the testimony urged CMS to use the 21 rehabilitation impairment categories (RICs) from the prospective payment system to determine compliance with the 75% rule (for more information, see the June issue of Rehab Continuum Report). This position is advocated by a rehab coalition comprising such organizations as the American Hospital Association, the American Medical Rehabilitation Providers Association (AMRPA), and the American Academy of Physical Medicine and Rehabilitation. Barker
told Rehab Continuum Report before the meeting that CMS is not inclined to use the RICs. After hearing the testimony, he says his opinion has
"It interested me that there was diversity of opinion in the field. Everyone was not just parroting AMRPA’s line," Barker says. "There were people who said the real problem here is polyarthritis, and that you don’t need to use the RICs as the basis for definition. That confirms what I already believed to be the case."
Barker did hear a couple of new ideas that he says are worthy of consideration. One speaker urged CMS to determine compliance with the 75% rule by counting patient days instead of discharges. Another advocated looking at Medicare discharges only, which is the process CMS uses for long-term acute care hospitals.
Ken Aitchison, president and CEO of Kessler Rehabilitation Corporation in West Orange, NJ, joined the meeting by conference call. He says he heard an entirely different message. "I heard an overwhelming number of statements that said to CMS: Change the rule. It’s outdated and inappropriate," he says. "Why in the world would anybody put a rule out defining who is to be included in the case mix groups knowing that less than 20% of the population would qualify? It’s CMS’ own definition that causes the rehab field not to be compliant. What is the goal here? It sure as heck is not providing access. It’s illogical."
Harold Ting, PhD, senior vice president of planning, marketing, and communications at Good Shepherd Rehabilitation Hospital in Allentown, PA, drew laughter at the meeting when he jokingly suggested that Tom Scully, CMS administrator, should only receive 50% of his pay since he spends only half of his time on Medicare.
"To illustrate the absurdity of this type of rule further, would it make sense to say an OB/GYN should not be considered an OB/GYN if a certain percentage of his services were not deliveries? Should we say an attorney is not providing legitimate legal services because he is not billing 75% of his time for services most lawyers provide? The answer is, of course not. Why is inpatient rehabilitation any different? It just doesn’t make sense," Ting said.
The comment drew Scully’s attention. "The fundamental issue for me is we pay rehab hospitals more than acute care hospitals," he said via conference call to the meeting participants. "If rehab hospitals want to act like acute care hospitals, fine. But we shouldn’t be paying them for it. I like rehab hospitals; I think they do some wonderful things. But there’s got to be some categories of why rehab hospitals are rehab hospitals.
"The fundamental question for me is why should rehab hospitals get paid more, because the issue is that for some of these patient groups, the same care can be done in acute care hospitals that get paid less," he said. "That’s a giant hurdle to get over for me. There’s got to be some differentiation between an acute care hospital and a rehab hospital or we shouldn’t have rehab hospitals, period."
Scully said there must be a definable reason why patients are sent from one part of the hospital to another. "Obviously if the government doesn’t define the differences, people will just chase the higher payment, which is not what we’re after and what unfortunately seems to have happened in many cases," he said.
Aitchison says he thinks most rehab providers don’t understand Scully’s point of view. "There’s a disconnect between his view and what the rehab community is saying," Aitchison says. "The rehab field has said we have no problem abiding by a rule that makes good sense. But this one makes no sense. We have no problem with saying medical necessity ought to dictate where the patient goes."
Providers have until July to send written comments to CMS on the proposed rule. The final rule will be published by the first of August. But Aitchison says he doesn’t think more comment will help. "This is so frustrating. We’ve worked long and hard, and I just don’t see where we’re getting anywhere. This is getting to the boiling point of frustration with so many of us," he says. "If the executive branch is not listening, we will have to go to the legislative branch."
Rochelle Archuleta, senior associate director for policy development — post-acute care for the American Hospital Association in Washington, DC, says the rehab coalition will turn its attention to writing formal comment letters on the rule and supporting legislation. Congressman Frank LoBiondo (R-NJ) introduced a bill (H.R. 2246) along with 11 co-sponsors on May 22 that would require CMS to use the 21 RICs to determine compliance and would prevent retroactive reinforcement of the 75% rule.
Archuleta says the rehab field showed a united front at the town hall meeting. "Anybody who thinks that the field wasn’t unified is selectively listening," she says. "People kept saying the rule is out of date, that it hasn’t kept up with medical practice. We heard that from virtually everybody."Need More Information?