Access to Post-Acute Care for Persons who Need Rehabilitation

Trudy Mallinson, Ph.D., OTR/LRehabilitation Institute of Chicago

Northwestern University

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

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

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

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)

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)

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

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)

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

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

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)

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

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)

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)

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

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

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.

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)

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

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

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

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

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

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

Available Databases for IRF

• MedicareProvider of Service FileHospital Cost ReportsBeneficiary Files

• Proprietary eRehabDataUDSmr

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

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?

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

Acknowledgments

•Health Services Research – Disability and Rehabilitation Research Project on Medical Rehabilitation (H133A030807)

The End