HCFA changes assessment tool, so what will happen to reimbursement rates?
HCFA changes assessment tool, so what will happen to reimbursement rates?
MDS-PAC is out; FIM is in
The more than 400 letters and comments that rehab providers sent to the Health Care Financing Administration (HCFA) in Baltimore convinced the government to revise its proposed patient assessment instrument for the rehabilitation prospective payment system (PPS). The new tool will be far simpler and less time-consuming and is based on the adult Functional Independence Measure (FIM) instrument, which is what most rehab providers already use.
The new tool, called the Inpatient Rehabilitation Facility - Patient Assessment Instrument, will be used at assessment at admission and discharge. The tool has three pages with 54 numbered items. On the other hand, the Minimum Data Set - Post Acute Care (MDS-PAC) had more than 350 pages and would have required up to five assessments. The new tool is estimated to take about 30-40 minutes to complete, whereas the MDS-PAC would have required a couple of hours. (To see copy of revised proposed assessment instrument, click here.)
Another major improvement is that the new tool uses nearly the same rating scales as used in the FIM, while the MDS-PAC would have had a separate and completely opposite rating scale to the FIM. Rehab industry experts and providers say they are very pleased with the change, and they give HCFA credit for listening to their concerns. Now, the only remaining question is what HCFA will do in regard to the concerns centering around the weights applied to comorbidities and reimbursement rates.
"Basically, we’re very pleased with the proposed assessment tool," says Barbara Marone, MBA, senior associate director of policy for the American Hospital Association in Washington, DC. "We could fine-tune this and tweak it a bit, but we’re really just pleased that they were so responsive to the field," Marone adds.
HCFA’s move to make the major assessment tool changes is a clear indication that it understands that acute inpatient rehabilitation is a different level of service from either skilled nursing care or home health care, says Susan Cerletty, senior vice president and chief operating officer of Rehab Institute of Chicago. Rehab Institute is the top rehab provider in the country and has 39 locations in Illinois, representing more than 300 beds either through ownership or partnerships. "Certainly with the adoption of the FIM tool, we know that rehab facilities will be able to transition to the new system more easily," Cerletty says.
Some small rehab units unfamiliar with FIM
While about 85% of rehab units use the FIM, 45% of the small rehab units inside hospitals still don’t use the instrument, so the training and implementation process will be more complex for these facilities, Marone says. "There will be a bit of a learning curve for our members who are more likely to be hospital-based units," Marone adds.
The other issue with the change is timing. Rehab providers wonder whether HCFA will be able to implement PPS by October because there’s still a need to create software that will enable HCFA and rehab facilities to exchange information by computer, Cerletty notes.
Still, it’s a good sign that HCFA has published its revised tool within a few months of the end of the comment period on the proposed rule, because it brings the industry a little closer to the Oct. 1, 2001, implementation date, says Carolyn Zollar, JD, vice president for government relations, American Medical Rehabilitation Providers Association in Washington, DC. "There are some things that need to be clarified, and we hope that whatever HCFA has to do [to clarify its intent] can be done as quickly as possible," Zollar says.
Obviously, the shorter, new assessment instrument is a vast improvement over the MDS-PAC and will make life a lot easier for rehab facilities and their staffs, says Sheldon Herring, PhD, clinical director of the traumatic brain injury program at Roger C. Peace Rehabilitation Hospital, which is part of the Greenville (SC) Hospital System.
Rehab providers wait for other changes
"Everyone is breathing a sigh of relief and waiting for the other changes," Herring says. "We still don’t know the financial information and the calculations." Herring says he still is concerned about the cognition scales, which he views as somewhat weak for certain populations, and he’d like to know what HCFA intends to do about factors affecting cost and length of stay. HCFA may find that it’s necessary to look in more depth at the area of cognition for stroke and head injury cases. Neither the MDS-PAC nor the current proposed assessment instrument is psychometrically sound in that area, Herring states.
Another detail that needs to be addressed is the disproportionate share calculation, which is the effort to recognize the cost of serving low-income people. The buzz in the field has it that there will be an effort to make sure the adjustment is not so dramatic as it appeared to be in the proposed rule, Zollar says. "If you ended up with a policy incentive and everyone is depending on the disproportionate share for how the payment is calculated, then it’s not from a policy perspective what a prospective payment system is all about," Zollar says. "The net result of that is that it should increase, and we’d be hopeful it will increase the conversion factor."
Herring says the disproportionate share calculations could have a major impact on his facility’s program. "It’s nice to know that data collection will be easier, but we really need to know more about the actual reimbursement," he adds.
The Rehab Institute of Chicago also treats a fairly large share of people who are disadvantaged, Cerletty says. "Refining the disproportionate share calculation is not a bad idea," she adds. "We just need to be certain it will do what it’s intended to do, and that is to provide reimbursement to hospitals that are caring for more of these disadvantaged patients because they typically have more medical needs than patients from more affluent socioeconomic backgrounds."
Rehab providers should soon learn more about reimbursement under PPS, and that’s the most important issue, Herring says. "It’s almost like the debate over the MDS-PAC was somewhat of a distracter to the field because the largest issue always has been the actual reimbursement levels and how it will impact individual hospitals," Herring says. "We still want to see the final formula so that we can begin to look at our actual costs in relationship to anticipated reimbursement levels."
Need more information?
— Susan Cerletty, Senior Vice President, Chief Operating Officer, Rehab Institute of Chicago, 345 East Superior St., Chicago, IL 60611. Telephone: (312) 238-4541.
— Sheldon Herring, PhD, Clinical Director, Traumatic Brain Injury Program, Roger C. Peace Rehabilitation Hospital, Greenville Hospital System, 651 S. Main St., Greenville, SC 29601. Telephone: (864) 241-2600.
— Barbara Marone, MBA, Senior Associate Director of Policy, American Hospital Association, 325 7th St. NW, Washington, DC 20004. Telephone: (202) 626-2284. Web site: www.aha.org.
— 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. Web site: www.amrpa.org.
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