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HCFA being urged to change its approach
As the clock ticks toward the Oct. 1, 2000, deadline for implementation of a Medicare prospective payment system (PPS) for rehabilitation providers, the Health Care Financing Administration (HCFA) is being urged to modify its current approach to the PPS and to implement a system that is preferred by many in the rehabilitation field.
The American Medical Rehabilitation Providers Association (AMRPA) recently picked up support for some of its recommendations to HCFA on details of the PPS. Consider the following recent events:
• The Medical Payment Assessment Commission’s (MedPAC) annual report to Congress is expected to recommend that the rehab PPS utilize the Functional Independence Measure-Function Related Groups (FIM-FRGs) for patient classification, and that reimbursement be on a per- episode rather than per-diem basis.
The FIM-FRG-based classification measure would use the FIM and historical patient data in the Uniform Data System for Medical Rehabilitation’s extensive database of functional outcomes information. Many in the rehab field believe the use of this instrument would more accurately reflect the specific needs of rehab patients. Rehab professionals are concerned that, with per-diem rates, inpatient providers would be inclined to keep patients until they are completely functional, rather than sending them home with outpatient or home health services. Using the current per-episode rate, inpatient providers release patients more quickly. Since there is a cap on the total amount of money HCFA can spend on rehab services, the agency argues that per-diem rates ultimately would decrease, resulting in longer stays and fewer services for patients.
MedPAC, an advisory board that makes recommendations to Congress on payment, policy research, and other Medicare issues, was scheduled to publish its report March 1. (The full report is available on MedPAC’s Web page at http://www.medpac.gov.)
Under MedPAC’s recommendation, the FIM-FRG would not be tested on skilled nursing facility (SNF) patients who are medically complex long-term patients, only on those who go to the SNF specifically for rehabilitation, such as following a stroke or a hip replacement.
• U.S. Rep. Pete Stark (D-CA), the ranking Democrat on the House Ways and Means subcommittee on health, has asked William J. Scanlon, PhD, director of health financing and systems issues for the Government Accounting Office to evaluate some of the concerns expressed by professionals in the rehabilitation field and to discuss them with HCFA officials before final decisions are made on the PPS.
He repeated concerns of rehab providers "both individually and through associations" about the per-diem reimbursement systems and HCFA’s plan to develop patient classifications and case weights from a small sample of cases.
"Rehabilitation providers feel that use of such a small sample will inevitably lead to inaccurate classification and payments. As a consequence, there will be inappropriate rewards for treating some types of patients and financial penalties for treating others," Stark said in his letter.
Specifically, the AMRPA has been recommending to HCFA:
— that payments under the PPS be based on a per-episode rate instead of a per-diem rate as proposed by HCFA;
— that patient classifications and weights be based on the methodologies using the FIM-FRGs (these were developed for HCFA by RAND Corp. in Santa Monica, CA);
— that HCFA’s patient assessment system for post-acute services, the Minimum Data Set-Post Acute Care (MDS-PAC) include the FIM rating scale used by virtually all medical rehabilitation providers. (For more details, see AMRPA’s Web page at http://amrpa.firminc.com.)
HCFA still leans toward a per-diem reimbursement rate based on a different classification and case-weight study, scheduled for release this spring, and a version of the MDS that encompasses some, but not all, elements of the FIM. However, the AMRPA has picked up support for its position.
Meanwhile, the organizations that have contracted with HCFA to research the proposed PPS are moving ahead with their work.
"HCFA has made it clear to us that we have a contract and that we have a timeline, and that is what we are marching to. Any policy changes will be dealt with at the HCFA level. We don’t worry about it day-to-day in the trenches," says Robert E. Burke, PhD, vice president at Washington, DC-based Muse & Associates and principal investigator for the HCFA’s patient classification system project.
Under their joint contract with HCFA, Muse & Associates and Aspen Systems in Rockville, MD, will begin staff time measurement studies at a sampling of rehabilitation hospitals and units this spring. Using the MDS-PAC assessment instrument, the researchers will determine a patient classification system based on resource allocation. Their final report is due to HCFA in April 2000.
(For additional information on the Aspen Systems/Muse & Associates research, see Rehab Continuum Report, January 1999, p. 1.)
The Research and Training Institute at Hebrew Rehabilitation Center for the Aged in Roslindale, MA, is expected to submit its final report to HCFA by March 31 on the MDS-PAC. The institute’s original deadline, Feb. 1, was extended. (For information on the Hebrew Rehabilitation Center for the Aged research, see RCR, August 1998, p. 101.)
Field testing of Draft 8 of the proposed patient assessment instrument began in January at 120 sites, including long-term care hospitals, rehabilitation hospitals, freestanding SNFs and SNF units, and transitional care units in hospitals. The field test should involve more than 4,000 patient assessments, according to Pauline Belleville-Taylor, RN, MS, CS, project director. A smaller field test may be done as a reliability test, she says.
Draft 7 of the MDS-PAC, which was pilot-tested in the fall, had more than 350 items. The final document will have fewer, Belleville-Taylor says. The number and type of items to be dropped will depend on what the field test research shows, she adds.
"It’s clearly too long. Some items will be dropped. We are looking at time factors. We don’t need another two-hour assessment like the MDS-RUGS [the assessment instrument used in nursing homes]," Belleville-Taylor explains.
However, she says, the HCFA contract calls for an assessment instrument that is to be used in a variety of post-acute settings, which makes it difficult to shorten.