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If the letters received by the American Medical Rehabilitation Providers Association (AMRPA) in Washington, DC, are any indication, then the Health Care Financing Administration (HCFA) is about knee-deep in suggestions, criticism, and comments about the inpatient rehabilitation prospective payment system (PPS).
"I’m looking at over two feet high of letters that our members have sent to HCFA and to their members of Congress and other people who remain in the government," says Carolyn Zollar, JD, vice president for government relations for AMRPA.
It will take a while for HCFA administrators to read through the letters and packages sent by rehab facilities across the nation, and this is one reason why the agency decided to postpone PPS implementation indefinitely, according to HCFA’s recently released question-and-answer statement. (See "HCFA answers inpatient rehab PPS questions," in this issue.)
In other recent good news, the independent Medicare Payment Advisory Commission (MedPAC) recommended that HCFA use the functional independence measures (FIM) instead of the minimum data set for post acute care (MDS-PAC). This gives weight to the criticism coming from the rehab industry over the proposed use of MDS-PAC. It also unravels one of HCFA’s justifications for proposing the use of MDS-PAC. In proposing the industry use MDS-PAC, HCFA cited MedPAC’s desire to "seek sufficient data to devise a patient classification system that effectively predicts resource use."
"The MDS-PAC clearly remains our primary concern, both for its content and for its ability to reflect the structure of the classification system and the burden it will place on facilities," Zollar says.
Individual rehab providers also continue to express concern over MDS-PAC.
Schwab Rehabilitation Hospital & Care Network in Chicago will have to use both the FIM and the MDS-PAC instruments — at least for a while — if the MDS-PAC is selected, says Judy Waterston, chief executive officer and president of the 125-bed rehab hospital, which is affiliated with Sinai Health System in Chicago.
"They’re saying the MDS-PAC would take 85 minutes to complete," Waterston says. "We’re talking with colleagues in the field, and we hear that it is taking more than twice that length of time."
Particularly in these days of health care personnel shortages and other staffing issues, this is a major concern, Waterston adds.
Waterston’s letter to HCFA reflects this concern. The letter, sent this past January, reads, in part: "Schwab currently has over 20 full time openings in our clinical departments despite an active recruitment and retention program."
There are many good reasons why HCFA should scrap the MDS-PAC proposal and instead recommend making the FIM the Medicare instrument, Waterston adds. "When you change instruments, it’s hard on clinical staff, and the MDS-PAC and FIM scorings are reversed, so that’s problematic for clinicians," Waterston says. "It’s not that we don’t think we can learn the MDS-PAC, but there will be inadvertent mistakes made during a transition period."
On a positive note, many experts predict HCFA will delay implementing PPS until October 2001. "Given this longer window, I think it gives HCFA some time to fix some of the things the rehab field has commented on, and it gives HCFA time to think long and hard about what they’re going to do with MDS-PAC," says Barbara Marone, MBA, senior associate director of policy for the American Hospital Association’s (AHA) Washington, DC, office.
AHA’s letter to HCFA, dated Jan. 26, 2001, states that the "AHA is extremely troubled that the benefits of HCFA’s regulatory requirements for data collection under PPS are greatly outweighed by immense regulatory costs imposed by use of the Minimum Data Set-Post-Acute Care (MDS-PAC), both the number of data elements it contains and the frequency with which it is used to assess patients."
The AHA letter further states that the organization, which represents 5,000 hospitals and health systems, supports MedPAC’s recommendation to use the FIM for rehabilitation PPS. (See "Comments on rule give HCFA plenty to review," in this issue.)
The rehab industry expressed other major concerns about the proposed PPS rule. Among these are issues concerning HCFA’s proposed transfer policy, the list of comorbidities, and the outlier policy. Here are some of the rehab industry experts’ concerns:
• List of comorbidities: Rehab providers say the comorbidities listed as part of the proposed rule’s case mix groups do not adequately reflect what they are seeing with their patients. For example, Schwab Rehabilitation Hospital provides care to patients who have suffered spinal cord injury, traumatic brain injury, stroke, and amputation, all of whom often have a variety of comorbidities that are complications of their disabilities, says Suzan L. Rayner, MD, MPH, an executive vice president for medical affairs and medical director at Schwab.
Rayner explained the problems the listed comorbidities pose in a Jan. 19, 2001, letter to HCFA. "The original list of comorbidities has all kinds of things like TB, which is not relevant to our patient population, " Rayner says. "Our typical patient is a 68-year-old man who is a diabetic who had an amputation and who has hypertension, end-stage renal disease, and is on dialysis three days a week, and he may have a pressure sore from an acute hospital stay."
So the rehab staff has to help the patient manage his insulin levels and his hypertension, assist bringing the patient to dialysis, and still meet all rules and requirements as far as rehabilitation care is concerned. This means the patient’s care will be costly and the length of stay may be adversely affected by all the comorbidities, she adds.
"HCFA’s list of comorbidities doesn’t capture the type of patient we’re seeing in rehab facilities," Rayner maintains. "They have to look at the whole picture of the patient and not just label someone as an amputee, because that does not capture what’s going on with the patient medically."
Rayner lists the following comorbidities that occur often in severely disabled patients: dysesthetic pain, spasticity, electrolyte imbalance, depression, neurogenic bladder, urinary tract infections, pressure sores, autonomic dysfunction, seizures, deep vein thrombosis/pulmonary embolus, heterotopic ossification, incontinence, and fractures.
Any one of these comorbidities could add considerable time to the patient’s length of stay, Rayner explains. For example, stroke patients, spinal cord injury patients, amputees, and other rehab patients often suffer from depression. A patient’s depression may cause him or her to progress more slowly in rehab treatment and in self-management of health issues. Even if these patients are treated with antidepressants, it may take a couple of weeks for the medication to take effect, and two weeks often is the total length of time allowed for particular rehab patients.
Pressure sores and other wounds also take longer to heal than the proposed rule appears to allow. Rayner cites an example of how HCFA’s proposal allows only 1.1 extra days for some patients who have a comorbidity of a grade three pressure sore, although it’s obvious to those who work in the field that a grade three pressure sore takes longer than that to heal.
The AHA has a major concern that the inpatient rehab PPS will not deal adequately with medical complexity and the cost of treating medically complex patients, Marone says.
The AMRPA recommends to HCFA that additional comorbidities be added to the PPS rule and that HCFA examine the impact of multiple comorbidities on the cost of a case, relationship to transfer, and special cases. Further, AMRPA writes in the Jan. 29, 2001 comment letter, "Consider including complications that develop over the course of treatment and in the final weights, while balancing the need to assure high quality care with the possibility facilities will only seek higher payments."
• Transfer policy: HCFA needs to clarify how facilities will count the patient’s length of stay, writes Louise M. Gutierrez, Schwab controller, in a Jan. 19, 2001, letter to HCFA. "In many instances the average length of stay is a fraction (i.e., CMG 0101) is 10.4 days," Gutierrez writes. "If the patient is discharged on day 10, do we need to count the hours from admission to discharge for length of stay computation?"
Schwab also is concerned that HCFA does not address the fact that some patients are admitted from a nursing home and therefore would have entirely different length-of-stay expectations, according to Gutierrez’ letter. "If a nursing home is the patient’s domicile, we recommend that these patients be excluded from this section of the regulations," she writes.
Likewise, Schwab recommends that HCFA not apply the transfer policy to discharges to the community, which require home health or outpatient services, and the hospital asks that HCFA consider an increase in payment for long-stay transfers, which are not outliers.
• Outlier policy: Rehab is different from acute care, and the proposed rule’s outlier policy should reflect that difference, Zollar says.
"The issue I have is the whole system is based on averages, and outliers are a way to address someone who falls outside the average," Zollar explains. "A system of averages works really well with a large system that has a lot of cases, but rehab is very small, with only 360,000 cases total."
Moreover, the number of cases per rehab facility is quite small, with an average of 600 in freestanding rehab facilities and 250 in hospital rehab units, she adds. "So if you get a few of those outlier cases, you can see it will have a dire effect on your costs," Zollar says.
The AMRPA recommends that HCFA examine its outlier policy proposal to ensure that measures are implemented to prevent facilities with higher routine costs and a higher number of cases from being penalized. These measures could include lowering the threshold amount, paying more than 80% of the costs, and increasing the percentage of payments provided for outlier payments.
Schwab estimates indicate that the rehab hospital would have lost more than $450,000 in Medicare reimbursement under HCFA’s proposed rule regarding having an 80% cost reimbursement of costs exceeding the case mix group payment, plus the outlier threshold, Gutierrez comments in her letter to HCFA.
"The outlier policy appears to be penalizing facilities that treat patients with severe disabilities and comorbidities," Gutierrez adds.
• Barbara Marone, MBA, Senior Associate Director of Policy, American Hospital Association, 325 7th St. NW, Washington, DC 20004. Telephone: (202) 626-2284.
• Judy Waterston, Chief Executive Officer and President, Schwab Rehabilitation Hospital & Care Network, 1401 South California Blvd., Chicago, IL 60608. Telephone: (773) 522-2010.
• Carolyn Zollar, JD, Vice President for Government Relations, American Medical Rehabilitation Providers Association, 1606 20th St. NW, Suite 300, Washington, DC 20009. Telephone: (202) 265-4404.