New 75% rule could be disastrous for inpatient rehab, providers say
Plan could cut patient access, hospitals’ business
Rehab advocates have seen the future of inpatient rehab in a new proposed rule from the Centers for Medicare & Medicaid Services (CMS), and they say it doesn’t look bright. Comments on CMS’ proposed changes in the criteria for classifying hospitals as inpatient rehabilitation facilities range from disappointing to disastrous.
After two years of fighting the 75% rule, a coalition of rehab providers held out some hope that CMS might use the 21 rehabilitation impairment categories (RICs) from the prospective payment system to determine compliance. However, coalition members, including such groups as the American Hospital Association (AHA), the American Medical Rehabilitation Providers Association (AMRPA), and the American Academy of Physical Medicine and Rehabilitation, didn’t get nearly the relief they had anticipated.
The proposed rule, published in the Sept. 9 Federal Register, temporarily would reduce from 75 to 65 the percentage of patients who must fall into a list of diagnoses for the hospital to be paid as an inpatient rehabilitation facility. The list of the 10 most common conditions requiring rehabilitation was set in 1978 and includes stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur, brain injury, polyarthritis, neurological disorders, and burns. Rehab providers have argued that the list is outdated.
But the only change in the list proposed by CMS is to replace the term polyarthritis with three groups of conditions that will identify more precisely the types of arthritis-related ailments appropriate for care in a rehab facility. As a result, the proposed 65% rule would apply to a total of 12 medical conditions.
CMS is taking comments on the proposed rule until Nov. 3 and plans to publish a final rule as soon as possible after that date. The final rule would be effective for cost reporting periods beginning on or after Jan. 1, 2004, and before Jan. 1, 2007. CMS expects to save $223 million through these changes.
CMS also proposes to:
- Presume that if the facility’s Medicare population complies with the rule, then the facility’s total population complies.
- Count patients who have secondary medical conditions that fall into the 12 categories as part of the proposed 65%, but only if the secondary condition causes such a significant decline that the patient would need inpatient rehab even without the admitting condition.
- Use the most recent, appropriate, and consecutive 12-month period to review data to determine compliance.
- Change the compliance percentage back to 75% in three years.
"In this proposed rule, we are taking a fresh look at the current 75% rule to see if it should be changed," said CMS administrator Tom Scully in a news release. "We are proposing significant revisions to the rule."
To many rehab providers, the revisions aren’t nearly significant enough. Carolyn Zollar, JD, vice president for government relations at the AMRPA, says her organization doesn’t believe the proposal is of any assistance at all. "Our view is it’s very confusing," she adds. "The 65% is a good step forward, but when coupled with the other things, it really won’t provide adequate relief. The polyarthritis conditions are highly qualified. You have to have exhausted at least one other prior course of rehabilitation, so it’s very hard to say these provide any relief to the facilities."
Rochelle Archuleta, senior associate director for policy development post-acute care for the AHA in Washington, DC, says her organization is highly disappointed with the rule. "We look at it as being the same old 75% rule, except that it’s more restrictive," she says. "Dropping the threshold on a temporary basis to 65% does help some providers, but it certainly falls far short of the modernization of the rule that we were seeking."
Under the rule, some rehab facilities would have to drastically change how they view which patients are eligible for admission. "The initial reaction we’re hearing from our members is that this will be devastating," she says. "It would be a significant change in how they provide rehab care in their communities today."
Cardiac, pulmonary, cancer, and transplant patients who need rehab care will face significant barriers to access, Archuleta points out. "This doesn’t provide much in the way of allowing patients who we feel should be included in the 75% rule greater access to care. What you have are categories of patients that currently don’t count for the 75% rule that will continue to be shut out."
While CMS did address the polyarthritis issue, the AHA wasn’t happy with the result. "The narrowing of polyarthritis is incredibly severe, and we’re highly concerned about that," she adds. "Whenever we’ve had experienced physiatrists review the rule, they cannot imagine what the origin of this provision is. It’s so incredibly inconsistent with clinical practice."
One inpatient rehab unit that stands to lose a significant number of potential patients under the proposed rule is at St. Francis Hospital in Greenville, SC. St. Francis’ case mix leans heavily toward orthopedic patients. Joe Golob, PT, director of the 19-bed Inpatient Rehabilitation Center, says the proposal will make it hard to admit many of the joint replacement cases that are due to arthritis. "It requires that the patients have been receiving active and intensive treatment for that condition in other less intensive rehabilitation settings immediately preceding the inpatient admission."
Those patients may have to be sent to subacute or skilled nursing facility (SNF) beds, potentially increasing the overall length of stay because they won’t be getting the intensive rehab they need, he says.
Golob says the rehab unit has never been at risk for failing to meet the 75% rule in the past, under its interpretation of polyarthritis. But with CMS’s new definitions, that will change. "This will be a tremendous challenge to the inpatient rehabilitation industry."
St. Francis has the majority of the market for joint replacements in the area, with a steady stream of referrals filling the beds. "We will have to change our gears and go in a different direction," Golob says. "We will have to reroute patients, and we will have to be more discriminatory about the patients we allow to be part of the 35%. We will have to start marketing for stroke, neurological, and amputation patients."
Theresa Edelstein, vice president of continuing care services for the New Jersey Hospital Association (NJHA) in Princeton, says she, too, is disappointed with the proposed rule. New Jersey is the state where the whole polyarthritis debate erupted, and the NJHA doesn’t think this proposal helps at all. "The categories for polyarthritis are so limited, they essentially don’t make any difference," she says. "There is still a significant portion of the orthopedic population that our members serve that will, in essence, have significantly reduced access to inpatient rehab because of the way the proposal is constructed."
At best, those orthopedic patients will find alternating levels of access to care, depending on how close facilities are to the 65% threshold, Edelstein says. Such patients theoretically could be treated in an SNF, but she says the SNF Medi-care resources may not pay for everything the patient needs. That means the SNF wouldn’t be able to take that patient either.
"One of the really unsavory options is that the patient ends up staying in the hospital a heck of a lot longer than they really need to while the hospital struggles to find an appropriate placement," she says. "In New Jersey, we are struggling with Medicare length-of-stay issues. We have a growing elderly population, and if you squeeze tighter on the post-acute side, our length-of-stay problem on the acute side is only going to get exacerbated."
Bruce Gans, MD, a physiatrist and chief medical officer at the Kessler Institute for Rehab in West Orange, NJ, agrees that restricting rehab access only will create problems for acute care hospitals. "The health care system is so highly focused on through-put that the ideal admission to an acute care hospital is somebody who gets discharged the day before they get admitted," he jokes. "It’s absurd how much pressure there is.
"We no longer have acute care hospitals that provide a healing and caring environment. They only provide acute technical intervention just long enough until we can get you out the door to someplace else," he continues. "Rehab hospitals are largely that someplace else. If we have to say no, then acute beds will stay occupied. It backs up the emergency room, and the whole chain is all backed up. This is only going to increase the pressure on that piece of interconnectedness of the health care system."
Rehab hospitals can take much more complicated patients now than they could 25 years ago, Gans says. "We never used to be able to take a patient who needed intravenous medication, who needed tracheotomy, or ventilator management. At Kessler, now we don’t blink an eye if somebody’s a ventilator-dependent quadriplegic and on IV antibiotics and needs to be treated for deep vein thrombosis. We simultaneously provide rehab services. So there’s really more bang for the buck."
Many providers will have to turn their attention to finding new categories of patients who would benefit from rehab. There probably are enough patients out there to fill those beds, Gans says. "That’s said with embarrassment because it means we’ve still done a pretty poor job in this country of recognizing when somebody actually needs medical rehabilitation. So the good news is that this will put some extra oomph to finding those underserved people who would benefit from it," he says. "The risk of course is that we’re not taking care of people now who need to be taken care of. People don’t go to rehab hospitals as resorts. I’m very worried about how they’re going to get access to care."
Rehab providers are busily working on comments to the proposed rule. The coalition is still pursuing a legislative remedy as well, says Archuleta of the AHA. "We are seeking external analysis to identify the clinical characteristics of patients who should appropriately be treated in an IRF; we are suggesting a moratorium during the study period; and we want the threshold to be dropped to 50%," she says.
On Sept. 10, Sens. Ben Nelson (D-NE) and Jim Jeffords (I-VT) filed an amendment to the Labor/Health and Human Services appropriations bill being debated in the Senate. The bill (S.1222) would amend title XVIII of the Social Security Act, requiring the Secretary of Health and Human Services to use the 21 RICs as criteria for inpatient rehab payment. The bill also:
- places a moratorium on the proposed rule;
- reduces the 75% requirement to 50%;
- requires the Institute of Medicine to conduct a study to update the criteria and use that information to update the proposed rule.
Need more information?
Rochelle Archuleta, Senior Associate Director, American Hospital Association. Telephone: (202) 626-2320. E-mail: [email protected].
Theresa Edelstein, Vice President of Continuing Care Services, New Jersey Hospital Association, 760 Alexander Road, P.O. Box 1, Princeton, NJ 08543-0001. Telephone: (609) 275-4102.
Bruce Gans, MD, Chief Medical Officer, Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ 07052. (973) 243-8535.
Joe Golob, PT, Director of the Inpatient Rehabilitation Center, St. Francis Hospital, One St. Francis Drive, Greenville, SC 29601. Telephone: (864) 255-1953.
Carolyn Zollar, Vice President for Government Relations, American Medical Rehabilitation Providers Association, Suite 300, 1606 20th St. N.W., Washington, DC 20009. Telephone: (888) 346-4624.
Rehab advocates have seen the future of inpatient rehab in a new proposed rule from the Centers for Medicare & Medicaid Services (CMS), and they say it doesnt look bright. Comments on CMS proposed changes in the criteria for classifying hospitals as inpatient rehabilitation facilities range from disappointing to disastrous.
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