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One of the most controversial aspects of the inpatient rehabilitation prospective payment system (PPS) proposed rule is the requirement that rehab facilities use a new assessment tool, called the Minimum Data Set for Post Acute Care (MDS-PAC).
The Health Care Financing Administration (HCFA) in Baltimore, states in its proposed rule that the rehab industry did not have an appropriate and widely accepted functional status measure for inpatient rehabilitation until the functional independence measure (FIM) was developed in the 1980s. Using FIM data, researchers from the University of Pennsylvania developed a patient classification system called the functional related groups (FRGs). The FIM-FRGs are used by a majority of inpatient rehabilitation facilities.
HCFA estimates that the extra cost incurred in completing an MDS-PAC instrument will be a maximum of $94.91 per case. HCFA also estimates it requires a median amount of time of 85 minutes for a rehab professional to complete the MDS-PAC, and this compares with a median time consideration of 20 minutes to complete the FIM instrument.
Rehab industry experts want to know why HCFA officials decided to scrap FIM and force rehab facilities to use a new and untried measurement system that will cost them more money and staff time.
HCFA’s chief argument in favor of the MDS-PAC over FIM-FRG is that the MDS-PAC will help to move Medicare toward HCFA’s long-term goal of creating a more integrated post-acute care payment and delivery system.
"Our goal of ultimately establishing a common system to assess patient characteristics and care needs for post-acute providers was endorsed by MedPAC in its March 1999 report to the Congress," says HCFA in the proposed rule.
The MDS-PAC system is based on the Minimum Data Set/Resident Assessment Instrument (MDS-RAI), which is used in long-term care settings and was the first standardized assessment instrument that Congress required to be used in a post-acute care setting.
HCFA says that a drawback of the FIM assessment instrument is that it is specifically focused on functional improvement and lacks detail on the needs of the patient during the course of admission. Compared to the FIM-FRG, the MDS-PAC contains additional data items related to quality of care.
"Clearly, HCFA speaks throughout the proposed rule that quality is a major issue, so what is interesting to us is that all of the things they say the MDS-PAC can do are things the FIM can do now," says Carolyn Zollar, JD, vice president for government relations for the American Medical Rehabilitation Providers Association (AMRPA) in Washington, DC.
The quality items that the FIM lacks could easily be added to the FIM-FRG system rather than scrapping it for a whole new instrument, says Richard Linn, PhD, director of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research in Buffalo, NY, which provides rehab facilities with a FIM system.
Instead, HCFA is telling rehab facilities that they will have to completely retrain their staff to use a new and lengthy assessment tool that has a scoring system exactly opposite the FIM system. This will make it very difficult for therapists and others to produce accurate and high-quality data, especially during the first years of using the instrument, Linn says.
"If you suddenly had to learn that the color red means "to go," and green means "to stop" at a stoplight, how would feel about that?" Linn adds. "How many intersections would you go through by accident, and that speaks to the potential reliability of data as people are collecting information and learning the new system."
Moreover, the rehab industry has no way of knowing how HCFA will use the quality information it collects through the MDS-PAC, says Judy Waterston, chief executive officer and president of Schwab Rehabilitation Hospital & Care Network in Chicago. "We’re not against gathering and benchmarking ourselves on quality; that’s what we’re in the business to do," Waterston says. "But we’re not quite sure what HCFA plans."
There’s the added dilemma of what to do with non-Medicare rehab patients. Should rehab facilities continue to use the FIM-FRG or other instruments to assess them, or should everyone be switched to the MDS-PAC for simplicity’s sake?
Waterston weighs in on the side of using one instrument for everyone. "Eventually, that would be the preferable thing, to have one measurement tool and measure all patients on that," she says. "But the reason the industry is a little nervous is because we don’t know how long that’s going to take, and of course we’re not paid for time spent doing the assessment."
But the alternative would make the assessment process very confusing for therapists and others, she notes. "We have only a third of our patients on Medicare, and so if we continue to use the FIM system for our other patients, we’re going to have staff using two systems, which increases the likelihood of error, and that’s a concern."
Nonetheless, HCFA is less concerned about the inconvenience to rehab facilities that must train staff to use an entirely different assessment tool than HCFA is intent on using an assessment tool that is similar across post-acute rehab settings
"Our proposal to use an MDS-based approach comes from our conviction that the use of common item labels and definitions across different provider settings would be essential to monitoring patient care across different provider settings," HCFA writes.
HCFA considered using the FIM instrument as the post-acute tool, but found that nursing home staff did not feel comfortable making the level of distinctions required in the FIM.
Critics of HCFA’s proposal also point to the issue of whether the MDS-PAC even will work as a means of determining the PPS payment. "The government currently does not know whether or not this MDS-PAC instrument can be used for payment because it’s never been tested," Linn says.
HCFA constructed payment rates using FIM data. HCFA also used the FIM-FRG classification system to develop the case-mix groups, which will be used to classify patient discharges by FRGs based on a patient’s impairment, age, comorbidities, and functional capability. HCFA officials wanted to improve upon the FIM-FRG system in the ability to predict resource use.
"We have a new instrument, and the government doesn’t even know if it’s going to work," Linn adds. "How could they propose a rule using an instrument that’s unknown for validity and use for this payment system, which is its primary purpose?"
An initial draft of the MDS-PAC was developed in September 1997, and the subsequent pilot and field testing focused on the inter-rater reliability, clinical validity, and administrative feasibility and burden associated with the MDS-PAC instrument. HCFA plans to conduct field testing to establish validity, reliability, and equivalence for payment before the final inpatient rehabilitation PPS rule is published.
Despite the rehab industry’s criticism about the choice of the MDS-PAC, HCFA appears poised to continue with the new assessment system. The proposed rule says that inpatient rehabilitation facilities must complete a successful transmission of test MDS-PAC data to HCFA’s system during the month of February 2001. Then on April 1, 2001, rehab facilities must use the MDS-PAC for all assessments.
The assessment must be completed at set time points in the patient’s inpatient rehab stay, including day four, day 11, day 30, and day 60. The data from the day four assessment determines the case mix group classification, which in turn determines payment for the first three days of admission. (See HCFA charts of MDS-PAC schedule.)
The implication is that rehab facilities will have to begin using and training staff to use MDS-PAC now, even if it’s still uncertain whether the assessment instrument is included in the inpatient rehabilitation final rule for PPS.
"Until we use MDS-PAC, we won’t really know how it works out," Waterston says. Nonetheless, Waterston and others plan to send comments to HCFA about their concerns over the choice of MDS-PAC. "I don’t know how willing HCFA will be to change things based on our comments," Waterston says. "But the rehab industry is committed to at least bringing the issue forward."
|PPS Terminology in a Nutshell|
|Here’s a quick look at some of the terminology found in the proposed rule of the prospective payment system (PPS) for inpatient rehabilitation facilities:|
• CMGs: case mix groups
• CMI: case mix index
• DRGs: diagnosis-related groups
• FIM: functional independence measure
• FIM-FRG: functional independence measure - function related group
• HCFA: Health Care Financing Administration
• IRF: inpatient rehabilitation facilities
• MDS-PAC: Minimum Data Set for Post Acute Care
• MedPAC: Medicare Payment Advisory Commission
• RICs: Rehabilitation Impairment Categories
• TEFRA: Tax Equity and Fiscal Responsibility Act of 1982, Public Law 97-248
• UDSmr: Uniform Data Set for medical rehab
• David Good, MD, Director of Rehabilitation, Wake Forest Baptist Medical Center, Medical Center Blvd., Winston-Salem, NC 27157. Telephone: (336) 713-8600.
• Richard Linn, PhD, Director, Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research, 232 Parker Hall, Suny & Buffalo, 3435 Main St., Buffalo, NY 14214. Telephone: (716) 829-2076, ext. 34.
• Rajan Patel, Director, KPMG, 450 East Las Olas Blvd., Suite 750, Fort Lauderdale, FL 33301. Call Daniel Mucisko at (201) 505-3539, or e-mail: email@example.com.
• Judy Waterston, Chief Executive Officer, President, Schwab Rehabilitation Hospital & Care Network, 1401 South California Blvd., Chicago, IL 60608. Telephone: (773) 522-2010, ext. 5002.
• Carolyn Zollar, JD, Vice President for Government Relations, American Medical Rehabilitation Providers Association, 1606 20th St. NW, Suite 300, Washington, DC 20009. Telephone: (888) 346-4624 or (202) 265-4404. World Wide Web: www.amrpa.org.