Can you untangle web of outcomes information demands?

Payers, referral sources, public want different data

Today's rehab providers are caught in a tangled web of demands for information from managed care, Medicare, referral sources, accreditation agencies, the public, and the hospital's finance department, all of whom want somewhat different outcomes data. And with the advent of a Medicare prospective payment system (PPS) for rehab, providers face the possibility of tracking one set of data for Medicare reimbursement and another for managed care.

Just a few years ago, providers were tracking outcomes primarily as internal measures of quality. With the advent of managed care, payers wanted to know a provider's track record in getting patients functional. Providers negotiating capitated contracts found it necessary to know their costs vs. the outcomes they could expect to achieve based on historic data. It's no longer enough to point to your past history and show payers or referral sources how well you did. (For more on what your customers want to know, see story, p. 87.) "Outcomes are like yesterday's ball scores. You need to measure it, but the future of outcomes isn't saying what you did and how well you did it. Instead, providers need to be able to use their statistics to predict where the patient will go and to set up the most efficient type and venue of care," warns James Phillips, MS, chief executive office of the Uniform Data System for Medical Rehabilitation (UDSMR) in Buffalo, NY.

Here are some of the predictions you should be able to make with your outcomes data:

· What kind of therapy is needed, and how much it will take to restore a patient to his or her potential?

· Which part of the post-acute continuum is the most efficient and effective place to treat each patient?

· What types of treatment will give the best outcomes?

· What are costs likely to be for a particular patient in each of your venues of care?

· What outcomes are likely to be achieved by a patient in each level of the continuum?

· What are the direct and indirect costs for each diagnosis and subdiagnosis? (That information is vital when you negotiate managed care and capitated contracts.)

· How functional do patients remain after discharge to the community?

The UDSMR is analyzing ways to track a person with a disability through all venues of care, beginning at the acute hospital; continuing in the rehab setting, whether in the hospital or a subacute facility; and ending in outpatient and follow-up care.

"We are trying to develop linkages so we can use one system as a method of continuity that will track a patient's progress during the entire episode of care," Granger says.

The UDSMR is alpha testing an abbreviated version of the Functional Independence Measure (FIM) that can be used early on in an acute hospital stay.

Changing state of outcomes tracking

Outcomes measurement formerly focused on fixing the patient's problems - creating a definitive answer, says Colodia Owens, MA, principal of Interface Health Care Services in a El Sobrante, CA, a firm that consults on managed care and other reimbursement systems.

"Today's outcomes have become a little more nebulous because the primary goal is to focus on getting the patient ready to move to the next level of care in the least restrictive environment possible," she says.

The pressure to move patients quickly through the continuum isn't just from managed care organizations but from all payer sources, including Medicare, workers' compensation and Medicaid, Owens says. She cites a bill passed by the Calif ornia Legislature in 1997 that combines all types of health care funds previously earmarked for acute care, home care, and community services for the Medicaid population receiving long-term care and for disabled adults.

Geographical entities are charged with man aging the funds under the mandate that care is provided in the least restrictive environment possible.

"This legislation could possibly result in the reduction of the number of patients in a long-term care environment, as long as the patients are receiving the service they need without compromising their care," Owens says.

Other states have similar bills under consid eration. The California bill could affect how rehab providers handle certain patients, Owens asserts. As an example, she cites a Medicare stroke patient who lives alone.

"In the past, we probably would have considered sending the patient to the nursing home or assisted living. But with the paradigm shift in terms of the least restrictive environment, this patient will probably need to be discharged to home with community-based services," she says.

The social worker would be the most appropriate case manager for such a patient because of his or her knowledge of community resources, she adds.

Just 15 years ago, few providers were doing any kind of organized outcomes measurement. There was no common language for facilities to describe disability and no way for them to compare themselves with national norms.

In 1983, a task force organized, funded, and endorsed by national rehabilitation organizations developed the FIM as a method of documenting the severity of patient disability and tracking medical rehabilitation outcomes. The UDSMR set up a national database for rehab outcomes in 1987.

Today, 1,300 rehab providers subscribe to the UDSMR, which administers a database of more than 2.5 million assessments worldwide.

Although there are other methods for measuring outcomes in inpatient rehabilitation, the FIM is the most widely used, and one that most payers and referral sources understand.

When officials from the Health Care Financing Administration (HCFA) began talking about developing a single reimbursement system for post acute care that would be based on the Minimum Data Set-Resource Utilization Groups (MDS-RUGS) tools being used in long-term care, ripples of panic spread through the rehabilitation industry. For some time, rehab providers had pinned their hopes on the FIM-FRGs (functional related groups) being used as a basis for a PPS for rehab.

Speaking to participants at the joint conference of the American Hospital Association and the American Rehabilitation Providers Associa tion in Atlanta last year, Thomas Hoyer, director of the chronic care purchasing policy group of HCFA's Center for Health Plans and Providers, made it clear that the rehabilitation PPS would be based on the MDS-RUGS. That approach would build a unified reimbursement system that could lead to bundling reimbursement for post-acute services.

The UDSMR and the American Medical Rehab ilitation Providers Association have urged HCFA to modify the MDS to include the FIM data and to use information from a RAND Corporation report on the FIM-FRGs to devise a payment system.

[For more on the Uniform Data System for Medical Rehabilitation, call (716) 829-2076. For information on CARF...The Rehabilitation Accreditation Commission, call (520) 325-1044. Colodia Owens may be reached at (510) 669-1323.]