Access to PostAcute Care for Persons who Need Rehabilitation

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Access to Post-Acute Care for Persons who Need
Rehabilitation

• Trudy Mallinson, Ph.D., OTR/L
• Rehabilitation 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.
Total Medicare payments from 1986 to 1996 by
provider type (in billions)
http//www.ahapolicyforum.org/trendwatch/twjune199
9.asp
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Medicare Spending for Post-Acute Care, by
setting, 1992-2001
MedPAC, 2003
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PAC PPS Comparison
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).

UDSmr reports, Am J PMR, 1996 - 2002
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Early Impact the IRF PPS

• PPS increases pressure to reduce LOS
• CMS 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
Based on eRehabData discharges, 2002 (n2,157)
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Function at discharge trends down with LOS
(2002-Q1 2004)
eRehabData, 2004
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Discharge to community trends down
eRehabData, 2004
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Discharge to institution trends up
eRehabData, 2004
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Greater impact on persons with chronic
disabilities?
eRehabData, 2004
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Does this reflect a change in trend?
UDSmr reports, Am J PMR, 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 PAC
• Who gets admitted
• Timing, intensity and duration of service (within
  IRF)
• Multiple PAC use within an episode of care
• Use 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

• Medicare
• Provider of Service File
• Hospital Cost Reports
• Beneficiary Files
• Proprietary
• eRehabData
• UDSmr

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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 rule
• Previously 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 cant 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