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)
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.
Total Medicare payments from 1986 to 1996 by provider type (in billions)
http://www.ahapolicyforum.org/trendwatch/twjune1999.asp
Medicare Spending for Post-Acute
Care, by setting, 1992-2001
HHA IPS (1997)
HHA PPS (2000)
SNF PPS (1998)
IRF PPS
(2002)
LTCH PPS
(2002)
MedPAC, 2003
PAC PPS Comparison
SNF
HHC
IRF
LTCH
Per Day
Per 60-day
episode
Per discharge
Per discharge
MDS
OASIS
IRF PAI
None
44 RUG-III
groups
80 HHRGs
100 CMGS +
tiers
None (DRGs)
None
Fewer than 5
visits; high-cost
outliers
Short stay,
deaths,
transfers, highcost outliers
None
Unit of Payment
Measure
Product/Service
Classification
Product/Service
boundaries
Incentives
MedPAC, 2002
Limit services
received on
daily basis
Limit costs over entire stay, front
load services, discharge early;
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
Length-of-Stay Pre PPS
in ALOS of
Medicare patients
in IRFs from
• 15.4 days (RAND)
in 1999 to 13.2 in
2002 (eRehabData).
30
25
Days
20
15
10
5
0
1992
1993
1994
1995
1996
1997
UDSmr reports, Am J PM&R, 1996 - 2002
1998
1999
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
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
58.5
13.8
13.6
58
57.5
13.2
57
13
12.8
56.5
12.6
56
12.4
55.5
12.2
55
12
Q1 02 Q2 02 Q3 02 Q4 02 Q1 03 Q2 03 Q3 03 Q4 03 Q1 04
FIM Motor at Discharge
eRehabData, 2004
Length of Stay
Days
FIM Motor Score
13.4
Discharge to community trends
down
All Medicare Discharges
77.4
2 points = clinically
meaningful change
(Deutsch, 2002;
Buchanan; 2003)
88
87.5
77
76.8
87
76.6
76.4
86.5
76.2
76
86
75.8
75.6
85.5
2002
2003
Percent Discharge to Home
eRehabData, 2004
Q1 2004
FIM at Discharge
FIM Motor at Discharge
Percent Discharge to Home
77.2
Discharge to institution trends
up
All Medicare Discharges
88
23
87.5
22.5
87
22
86.5
21.5
86
21
85.5
2002
2003
Percent Discharge to Institution
eRehabData, 2004
Q1 2004
FIM at Discharge
FIM Motor at Discharge
Percent Discharge to Institution
23.5
2 points = clinically
meaningful change
(Deutsch, 2002;
Buchanan; 2003)
Greater impact on persons with
chronic disabilities?
Discharge to Institution - Medicare Only
Discharge to Community - Medicare Only
40
80
35
30
60
Percent
Percent
70
50
25
20
15
10
40
5
30
0
STROKE
HIP FRACTURE
2002
eRehabData, 2004
2003
Q1 2004
ALL
STROKE
HIP FRACTURE
2002
2003
Q1 2004
ALL
Does this reflect a change in
trend?
All Medicare Discharges
100
77.4
14
88
10
90
8
85
6
87.5
77
76.8
87
76.6
76.4
86.5
76.2
76
86
FIM Motor at Discharge
12
95
Percent Discharge to Home
77.2
75.8
80
4
75.6
85.5
2002
75
2
70
Percent Discharge to Home
0
1993
1994
1995
1996
1997
1998
Q1 2004
FIM at Discharge
All Medicare Discharges
1999
DSCINT
FIMDSC
UDSmr reports, Am J PM&R, 1996 - 2002
Percent Discharge to Institution
23.5
DSCCOMM
88
23
87.5
22.5
87
22
86.5
21.5
86
21
85.5
2002
2003
Percent Discharge to Institution
eRehabData, 2004
Q1 2004
FIM at Discharge
FIM Motor at Discharge
1992
2003
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 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 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, forprofit 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
• Medicare
 Provider of Service File
 Hospital Cost Reports
 Beneficiary Files
• Proprietary
 eRehabData
 UDSmr
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
• 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