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Access to Post-Acute Care for Persons who Need Rehabilitation
Trudy Mallinson, Ph.D., OTR/LRehabilitation Institute of Chicago
Northwestern University
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Post-Acute Care Providers that Provide Rehabilitation Services• Inpatient Rehabilitation Facilities (IRFs)• Skilled Nursing Facilities (SNFs)• Home Health Agencies (HHAs)• Long-Term Care Hospitals (LTCHs) • Other providers:
Outpatient Comprehensive Outpatient Rehabilitation
Facilities Adult Day Care
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Post-acute Care Rehab Settings• Medicare certification requirements vary by
PAC setting e.g. IRFs (3 hrs therapy/day, 24hr
medical supervision, 75% rule), SNFs (24hr nursing, limited MD, therapy hrs not specified)
• However, much of the the rehabilitation care provided is similar across settings and,• Many patients could potentially be treated
in more than one setting
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Medicare Expenditures
• In the mid 1980s, care provided in post-acute care settings was considered a cost-effective alternative to extended hospital stays
• By the early 1990s, care in post-acute care settings, including IRFs, SNFs, and HHAs had become the fastest growing area of the Medicare program
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Medicare spending for post-acute care has increased by more than
$33 billion.
http://www.ahapolicyforum.org/trendwatch/twjune1999.asp
Total Medicare payments from 1986 to 1996 by provider type (in billions)
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Medicare Spending for Post-Acute Care, by setting, 1992-2001
MedPAC, 2003
HHA IPS (1997)
HHA PPS (2000)
SNF PPS (1998)
IRF PPS (2002)LTCH PPS(2002)
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PAC PPS Comparison
SNF HHC IRF LTCH
Unit of Payment
Per Day Per 60-day episode
Per discharge Per discharge
Measure MDS OASIS IRF PAI None
Product/Service Classification
44 RUG-III groups
80 HHRGs100 CMGS +
tiersNone (DRGs)
Product/Service boundaries
NoneFewer than 5 visits; high-cost outliers
Short stay,deaths,
transfers, high-cost outliers
None
IncentivesLimit services received on daily basis
Limit costs over entire stay, front load services, discharge
early;
MedPAC, 2002
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Early Impact of PAC PPSs
• SNFs Percentage of patients receiving extremely
high levels of therapy decreased; percentage receiving moderate levels increased (White, 2003)
• HHAs Significant reduction in number of agencies
1997-2000 (NAHC, 2001) but # of visits was much more severely reduced (Liu et al, 2003; McCall, 2003)
Hospital-based HHAs made least reductions (McCall, 2003)
Therapy visits as % of episode increased 9% in 1997 to 23% in 2001, (MedPAC, 2003)
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Early Impact IRF PPS
• Continued decline in ALOS of Medicare patients in IRFs from
• 15.4 days (RAND) in 1999 to 13.2 in 2002 (eRehabData).
Length-of-Stay Pre PPS
0
5
10
15
20
25
30
1992 1993 1994 1995 1996 1997 1998 1999
Day
s
UDSmr reports, Am J PM&R, 1996 - 2002
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Early Impact the IRF PPS
• PPS increases pressure to reduce LOSCMS publishes average CMGt LOS
(for purposes of calculating short stay patients)
These LOS appear to have been interpreted as the upper limit on LOS
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ALOS for CMG 0114 (Severe stroke, no comorbidities) 2002
Average LOS (2002) = 22.3 days
Published (1999) Transfer LOS = 33 days
Based on eRehabData discharges, 2002 (n=2,157)
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Function at discharge trends down with LOS (2002-Q1 2004)
LOS and FIM Motor at Discharge - Medicare Only
55
55.5
56
56.5
57
57.5
58
58.5
Q1 02 Q2 02 Q3 02 Q4 02 Q1 03 Q2 03 Q3 03 Q4 03 Q1 04
FIM
Mo
tor
Sco
re
12
12.2
12.4
12.6
12.8
13
13.2
13.4
13.6
13.8
Day
s
FIM Motor at Discharge Length of Stay
eRehabData, 2004
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Discharge to community trends down
All Medicare Discharges
75.6
75.8
76
76.2
76.4
76.6
76.8
77
77.2
77.4
2002 2003 Q1 2004
Per
cen
t D
isch
arg
e to
Ho
me
85.5
86
86.5
87
87.5
88
FIM
Mo
tor
at D
isch
arg
e
Percent Discharge to Home FIM at Discharge
eRehabData, 2004
2 points = clinically meaningful change (Deutsch, 2002; Buchanan; 2003)
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Discharge to institution trends up
All Medicare Discharges
21
21.5
22
22.5
23
23.5
2002 2003 Q1 2004
Per
cen
t D
isch
arg
e to
In
stit
uti
on
85.5
86
86.5
87
87.5
88
FIM
Mo
tor
at D
isch
arg
e
Percent Discharge to Institution FIM at Discharge
eRehabData, 2004
2 points = clinically meaningful change (Deutsch, 2002; Buchanan; 2003)
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Greater impact on persons with chronic disabilities?
Discharge to Community - Medicare Only
30
40
50
60
70
80
STROKE HIP FRACTURE ALL
Perc
en
t
2002 2003 Q1 2004
Discharge to Institution - Medicare Only
0
5
10
15
20
25
30
35
40
STROKE HIP FRACTURE ALLP
erc
en
t
2002 2003 Q1 2004
eRehabData, 2004
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Does this reflect a change in trend?
All Medicare Discharges
75.6
75.8
76
76.2
76.4
76.6
76.8
77
77.2
77.4
2002 2003 Q1 2004
Per
cen
t D
isch
arg
e to
Ho
me
85.5
86
86.5
87
87.5
88
FIM
Mo
tor
at D
isch
arg
e
Percent Discharge to Home FIM at Discharge
70
75
80
85
90
95
100
1992 1993 1994 1995 1996 1997 1998 1999
0
2
4
6
8
10
12
14
DSCCOMM DSCINT FIMDSC
All Medicare Discharges
21
21.5
22
22.5
23
23.5
2002 2003 Q1 2004
Per
cen
t D
isch
arg
e to
In
stit
uti
on
85.5
86
86.5
87
87.5
88
FIM
Mo
tor
at D
isch
arg
e
Percent Discharge to Institution FIM at Discharge
UDSmr reports, Am J PM&R, 1996 - 2002
eRehabData, 2004
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Post-acute Care PPS
• Under PPS, each PAC setting has a unique method of reimbursement
• Creates non-neutral incentives for access and service provision. For example, the inpatient rehabilitation
system (IRF PPS), a fixed per episode payment, creates incentives to reduce length-of-stay
while the skilled nursing system (SNF PPS), a fixed per diem rate, creates incentives to reduce daily costs but not length-of-stay.
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Substitutability of Settings
• Lack of clear clinical guidelines about which patients are most appropriately cared for in which PAC setting
• Differing reimbursements may have made it advantageous for providers to admit and/or transfer patients within the PAC settings of their own organization, regardless of patient need. (MedPAC, 2003)
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Patterns of PAC Use
• In addition, pre-PPS, 19-22% of all PAC patients receive care in 2 or more PAC settings consecutively (Gage, 1999).
• Almost nothing is known about: patterns of PAC use across settings the costs associated with particular
patterns how providers have altered patterns of
PAC use in response to changing financial incentives
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Issues to Understand
• Defining Access to PACWho gets admittedTiming, intensity and duration of
service (within IRF)Multiple PAC use within an episode
of careUse of non-traditional, extender
settings
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Issues to Understand
• Provider Responses to PPS Tightening admission criteria to restrict
access to severe or unpredictable patients; Restricting services daily, during the
episode, or by reduced length-of-stay; Unbundling of services i.e. substituting PAC
“extender” services such as day rehab for the later portion of care;
Increasing use of LTCH and safety net hospitals as sites of rehabilitation;
Increasing use of multiple components of the PAC continuum in a single episode of care e.g. SNF to IRF to HHC
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Issues to understand
• Access to post-acute care is associated with:Patient factors:
Diagnosis, functional status, social support, age
Market (facility) factors: Geographic region, supply and ownership of
facilities and, managed care penetration
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Early Impact of IRF-PPS
• NIDRR HSR DRRP on Medical Rehabilitation - 5 year study, H133A030807
• Aim 1: Organization of Med. Rehabilitation Tom Prince, Elizabeth Durkin
• Aim 2: Access To Medical Rehabilitation Trudy Mallinson, Larry Manheim
• Aim 3: Patient Outcomes Allen Heinemann, Debbie Dobrez
• Aim 4: Comorbidities Debbie Dobrez, Anne Deutsch
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NIDRR HSR DRRP
• Aim 1 - Organization• Examine closings, mergers,
acquisitions• Impact of market factors
on restructuring• Impact of IRF
characteristics (unit or freestanding, for-profit status etc) on restructuring
• How responses to pressures are made (qualitative)
• Aim 2 - Access• Examine changes in
type and severity of patients admitted to IRFs
• Examine changes in PAC use (across episode)
• Effects greater for IRFs that are NFP, integrated with hospital, high pre-PPS costs relative to expected PPS revenues
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Available Databases for IRF
• MedicareProvider of Service FileHospital Cost ReportsBeneficiary Files
• Proprietary eRehabDataUDSmr
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Other issues impacting access to IRFS
• LMRPs (Local Medical Review Policies)Now LCDs, developed and enforced
by Fiscal Intermediaries (FIs)
• 75% rulePreviously not enforced, many
facilities do not currently comply
• Both of these will have a far greater impact on access to IRFs than PPS
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Longer-term issues
• What rehab is (black box), for whom rehab is effective Confounds issues of access because can’t
define who will do best in particular PAC settings
• Do patient outcomes vary across post acute care settings and what are the costs associated with the outcomes?
• What level of integration across the PAC-LTC continuum is needed to facilitate the most appropriate treatment decisions?
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What is NIDRR?
• National Institute of Disability and Rehabilitation Research• Organizationally located within the Office
of Special Education Resources within the Department of Education• Variety of funding mechanisms
Field initiated, Centers - Research and Training, Engineering and Research, Fellowships
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Acknowledgments
•Health Services Research – Disability and Rehabilitation Research Project on Medical Rehabilitation (H133A030807)
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The End