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It appears that the rehab industry has benefited from mistakes made with prospective payment systems (PPS) in the home care and skilled nursing facility industries, because the final rule reflects a more responsive federal government, rehab experts say.
"I think the final rule really does demonstrate a response to the public and to the professionals working in this field," says Bonnie Breit, MHSA, OTR, administrative director of rehabilitation services at Crozer-Keystone Health System in Upland, PA.
"Overall, we were extremely pleased with the components of the final regulations, especially with the patient assessment instrument," says Tom Davis, president of inpatient services for RehabCare Group of St. Louis.
The rehab industry benefited from being the third in a series of PPS implementations, says Barbara Marone, senior associate director of policy at the American Hospital Association in Washington, DC.
"We benefited from the learning curves of the home health and skilled nursing facility systems," Marone adds.
The Centers for Medicare and Medicaid Services (CMS) of Baltimore (formerly the Health Care Financing Administration) published the final rule for inpatient rehabilitation PPS on Aug. 7, 2001. The 500-plus-page document confirms earlier reports that CMS reversed its initial proposal that inpatient rehab facilities use the minimum data set for postacute care (MDS-PAC) for an assessment tool. The universally condemned MDS-PAC would have required facilities to invest in extensive staff training and likely would have added hours to the time therapists and clinicians needed to assess patients.
Instead, CMS will require facilities to use a tool called the Inpatient Rehabilitation Facilities Patient Assessment Instrument (IRF-PAI), which incorporates the functional independence measure (FIM). For most inpatient rehab providers, this means the new tool will be very similar to the tool they already have been using for quality and accreditation purposes.
"There will be changes from the way the FIM works, and those changes will make a difference, so I think training is going to be extremely important," says Carolyn Zollar, JD, vice president for government relations at the American Medical Rehabilitation Providers Association (AMRPA) in Washington, DC.
"But the implementation won’t be as time- consuming," Zollar adds.
CMS received volumes of comments that criticized the MDS-PAC proposal, with AMRPA and others questioning the tool’s reliability and validity with regard to assessing quality of care. Criticism also centered around the sheer size of the tool, which had more than 350 items and would have taken more than an hour to complete. Also, it would have required up to five assessments.
The IRF-PAI is much shorter, with only 54 numbered items, and only needs to be completed at admission and at discharge.
"So now there’s a lot less extra work for rehab units, and CMS has taken advantage of the systems that most rehab units have had in place," Davis says. "From that aspect, this is very good."
The FIM scale also is a more efficient tool with a much greater base of research supporting its validity, notes Laura Landmeier, OTR, MSOT, MBA, assistant vice president of quality and outcomes management with Schwab Rehabilitation Hospital & Care Network in Chicago.
However, not everyone will benefit from use of the FIM. The Children’s Institute of Pittsburgh might lose up to half of the Medicare reimbursement it currently receives for treatment of children who have the rare Prader-Willi Syndrome, says Charles Schuessler, vice president of finance and treasurer for the institute.
Prader-Willi Syndrome is a chromosomal disorder that results in children experiencing extreme hunger all the time. These patients will eat anything and typically are very obese, with low muscle tone, mild developmental delays, and behavioral problems. When Prader-Willi patients reach adulthood, many receive Medicare coverage because of their disability, Schuessler says.
"We have a fairly major problem because the patients in our Prader-Willi population do not fit the FIM scoring mechanism and never have been included in FIM data," Schuessler says. "So I don’t know if we could code our patients satisfactorily to get a claim processed."
The MDS-PAC tool also had no mechanism for a Prader-Willi diagnosis, so the institute had asked CMS to correct this omission. Unless CMS in some way exempts or recognizes Prader-Willi Syndrome as a separate diagnosis, the institute is facing a $500,000 annual loss in Medicare reimbursement.
The institute’s unique program treats Prader-Willi patients with a weight loss and behavioral modification program that focuses on improving motor skills and muscle tone. Prader-Willi patients typically have a 60-day length of stay at the institute.
"This truly is a quandary for us, and we’ll struggle to find a way to work through this," Schuessler says. "We don’t want to turn our backs on a need we’ve been serving for so long, but there obviously are limits to how much loss we can sustain."
Even those in the rehab industry who are mostly pleased with the inpatient rehab final rule acknowledge that there still are some problems to be resolved. These include the transfer rule, outliers, cost adjustments, the comorbidity list, and patient classifications. (See "Rehab experts air concerns about inpatient rehab PPS," in this issue.)
Also, rehab facilities will need to know when all of the necessary software and tools will be available for training and use.
"The critical question is, when will software for data tools be available so facilities can start downloading it and begin training on that," Zollar says.
"One thing all facilities need to be well aware of is if they want to be paid based on 100% of PPS at the very beginning, then they have to get their notification in to the fiscal intermediary 30 days in advance of the start of their cost-reporting period," Zollar adds. "For example, if a facility’s cost-reporting period is Jan. 1, 2002, then they need to get the request in and received by the fiscal intermediary no later than Dec. 1, 2001, and preferably before that."
Those who choose not to meet this deadline or who are unable to meet it will be subject to the two-year transition period, in which they’ll be paid two-thirds of their reimbursement based on PPS and one-third based on the current TEFRA system.