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The Health Care Financing Administration (HCFA) has set unrealistic deadlines for commenting on and implementing the rehabilitation inpatient prospective payment system (PPS), hospital rehab experts say.
The American Medical Rehabilitation Providers Association (AMRPA) in Washington, DC, the American Hospital Association (AHA) in Chicago, and other organizations representing rehab providers asked HCFA to postpone its 60-day comment period, saying that it didn’t provide enough time for people to analyze its 700 pages of rule making and supplemental materials.
As a result of the requests, HCFA announced it would extend the deadline and give hospitals and organizations an extra month to comment.
"We were hoping we would have a 90-day comment period because in order to get the kind of background information or supporting information that HCFA would like in terms of validating our concerns, hospitals need time to look at this complicated regulation and see how it is going to affect our facilities," explains Susanne Sonik, director of the Section for Long-Term Care and Rehabilitation for the AHA.
HCFA remained silent on the request for weeks after the organizations sent a Nov. 21, 2000, letter, and so the AHA and AMRPA worked through the year’s end to complete their comments and suggestions for the PPS rule. (See the January 2001 issue of Rehab Continuum Report for article on industry’s comments on PPS.)
But the rehab industry has far more concerns about the proposed PPS rule than just the time constraints it imposes.
HCFA’s proposal to use the Minimum Data Set for Post Acute Care (MDS-PAC) is one of the industry’s chief concerns, says Barbara Marone, senior associate director of policy for the AHA in Washington, DC.
"Our attitude is that the benefits do not outweigh the cost of the MDS-PAC," Marone says. "We believe the data collection instrument that 60% of the field has used, the FIM [Functional Independence Measure], is a reasonable instrument for HCFA to use for PPS."
The FIM is shorter and has had its reliability tested by HCFA’s own contractors, Marone says. "It’s significantly less burdensome, and the field understands how to use it, and it’s better designed for rehabilitation than is the MDS-PAC."
HCFA’s proposed rule stated that one of the main reasons the agency decided to recommend use of the MDS-PAC was because it is similar to the instrument already used by the long-term care industry and thus would potentially improve the post-acute care continuum.
Marone says that while this is a good goal, it just doesn’t work the way HCFA has proposed it. "They have the MDS for skilled nursing facilities, and then they have a separate system for home health care, and then they’re trying to retrofit the skilled nursing facilities’ instrument for rehab," Marone says. "It’s not a good fit."
Instead, HCFA should let the rehab industry use the FIM instrument and conduct supportive research to develop a small core of common data elements between the post-acute care settings.
"Where they made their mistake is they try to get everything and have cast their net really wide before they figure out what they really need," Marone says. "In this era that’s an incredibly wasteful and inefficient strategy."
Marone attended the December meeting of the Medicare Payment Advisory Commission (MedPAC) and says she came away from that meeting hopeful that MedPAC would recommend use of the FIM over the MDS-PAC.
"They’ve been on record supporting some commonality across the post-acute continuum, but [at the meeting] they said they’d like to see that ultimately, but it’s not so easy to get there, and we need to be more careful," Marone recalls.
MedPAC staffers reported at the December meeting that hospitals have seen an average total margin decline to 2.8% in fiscal 1999, down from 4.3% in fiscal 1998. MedPAC also reported that about 37% of all hospitals lost money on their operations in fiscal year 1999 and 34.1% of hospitals had negative margins that year from their inpatient Medicare operations.
The AHA also takes issue with how the proposed PPS deals with the medically complex patient. "The payment won’t be adequate," Marone says. "When patients have comorbidities and are complex and require a lot of resources, the system does a good job of predicting costs by length of stay, but doesn’t do a good job of predicting cost by intensity of resources."
The adjustment the proposed PPS makes for comorbidities is not enough to level the playing field, she adds.
As far as HCFA’s April 1 deadline, Marone predicts it will be extended. "With a new administration coming in, there’s no way the final rule will turn around and get out the door by the end of January, which is what they have to do to provide the 60-day lead time between the final rule and implementation of that rule," Marone says. "It’s not going to happen."
• Susanne Sonik, Director of the Section for Long Term Care and Rehabilitation, American Hospital Association, One North Franklin, Chicago, IL 60606. Telephone: (312) 422-3000.
• Barbara Marone, Senior Associate Director of Policy, American Hospital Association, 325 7th St. NW, Washington, DC 20004. Telephone: (202) 626-2284.