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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. Post-Acute Care Providers that Provide Rehabilitation Services. Inpatient Rehabilitation Facilities (IRFs)

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access to post acute care for persons who need rehabilitation

Access to Post-Acute Care for Persons who Need Rehabilitation

Trudy Mallinson, Ph.D., OTR/L

Rehabilitation Institute of Chicago

Northwestern University

post acute care providers that provide rehabilitation services
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
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
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.

Total Medicare payments from 1986 to 1996 by provider type (in billions)

medicare spending for post acute care by setting 1992 2001

HHA IPS (1997)

HHA PPS (2000)

SNF PPS (1998)

IRF PPS (2002)



Medicare Spending for Post-Acute Care, by setting, 1992-2001

MedPAC, 2003

pac pps comparison
PAC PPS Comparison

MedPAC, 2002

early impact of pac ppss
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
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 PM&R, 1996 - 2002

early impact the irf pps
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
alos for cmg 0114 severe stroke no comorbidities 2002

Average LOS (2002) = 22.3 days

Published (1999) Transfer LOS = 33 days

ALOS for CMG 0114 (Severe stroke, no comorbidities) 2002

Based on eRehabData discharges, 2002 (n=2,157)

does this reflect a change in trend
Does this reflect a change in trend?

UDSmr reports, Am J PM&R, 1996 - 2002

eRehabData, 2004

post acute care pps
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
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
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
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
issues to understand21
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 understand22
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
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
Available Databases for IRF
  • Medicare
    • Provider of Service File
    • Hospital Cost Reports
    • Beneficiary Files
  • Proprietary
    • eRehabData
    • UDSmr
other issues impacting access to irfs
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
longer term issues
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
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
Health Services Research – Disability and Rehabilitation Research Project on Medical Rehabilitation (H133A030807)Acknowledgments