Groups call for MDS to include FIM

They urge modification of rating scale

The Health Care Financing Administration (HCFA) is being urged to incorporate at least part of the Functional Independence Measure into the data collection tool for a prospective payment system for rehab.

The Uniform Data System for Medical Rehabili tation (UDSMR in Buffalo, NY) and the Washington, DC-based American Medical Rehabilitation Providers Association (AMRPA) have issued statements saying that incorporating the FIM into the Minimum Data Set (MDS) will make it possible to measure the characteristics of rehab patients more accurately.

While the committee from AMRPA has suggested that only the motor items of the FIM be included in the MDS, UDSMR officials have urged HCFA to include the five FIM cognitive items along with the 13 FIM motor items in the MDS. UDSMR officials have proposed a meeting between the AMRPA and the UDSMR so the two entities can present a unified front in discussions with HCFA.

UDSMR director Carl V. Granger, MD, sent a letter to subscribers in March asking them to write HCFA in support of joining the entire 18-item FIM with whatever instrument HCFA chooses for the rehab PPS. (See sample letter provided by the UDSMR to send to HCFA's subcontractor on the MDS-RUGS, p. 82.)

"By design, the FIM instrument includes only a minimal number of items but includes the domains that rehabilitation clinicians find to be critical in monitoring and evaluating rehabilitation treatments. Numerous national and international studies have shown the FIM instrument to be reliable and valid," Granger wrote.

In a meeting with HCFA officials, the PPS task force of the AMRPA has suggested the motor skills items of the FIM be incorporated into the MDS because rehabilitation is oriented to the restoration of physical and cognitive functions.

"The cognitive measures in the MDS appear to be sufficient but we believe the items dealing with motor skills, at a minimum, are too limited," AMRPA board chairman Dale Eazell, PhD, said in a report. (For AMRPA's criteria for a rehab PPS, see box, p. 82.)

However, Granger says both the cognitive and motor portions of the FIM should be used in the MDS because the two sets of items work in conjunction to predict future outcomes and costs. "While the motor items are important 'drivers' of the FIM-FRGs, the cognition items make statistically significant contributions at certain cut-points," he says.

Representatives from the UDSMR talked with HCFA officials to urge them to include the entire FIM in their data collection instrument, says UDSMR chief operating officer Kathy Dann. "Since they are trying to come up with a single instrument to be used across all post-acute venues of care, it has been our recommendation that they incorporate the entire FIM into the instrument," she says.

A licensing agreement between HCFA and the UDSMR will allow HCFA full rights to use the FIM as part of their PPS system, Dann says.

The agreement gives HCFA a royalty-free license to use portions of the FIM it selects in the development and operation of a PPS, Dann says. The agreement gives HCFA the right to sublicense the selected items to third parties to assist in developing or operating a PPS, to sublicense it to hospitals for use in determining their reimbursement, and the right to modify the FIM items, she adds.

Inclusion of the FIM in the MDS would help rehab providers who otherwise would have to use two different systems: the MDS for patients in the Medicare PPS; and the FIM, which would satisfy the demands of managed care payers, referral sources, and accreditation organizations that rely on it to provide information on expected patient outcomes and costs..

Representatives from AMRPA met in late April with HCFA's rehab PPS implementation team to give their input on how the rehab PPS should be structured. That includes recommendations the payment unit be made per discharge, that the motor ability items from the FIM be included in the MDS, and that case weights reflect analyses contained in a report on a PPS for rehab from the Santa Monica, CA-based RAND Corporation.

Carolyn Zollar, JD, general counsel for AMRPA, said the meeting was productive. "I felt like they listened to us. AMPRA is continuing in their efforts to guide HCFA in implementing a PPS that is in the best interest of rehab providers."

[For more details, contact AMRPA at (888) 346-4624. The UDS may be reached at (716) 829-2076.]