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Patient Oversight vs. Site-Neutral Payment; Patient Requirements Should be First

Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, January 20, 2015 Posted in: Inpatient Rehab

The complexity of care, treatment modalities and medication side effects, when discharged from acute care today, have shifted skilled needs and training for patients to manage their residual impairments to an alltime high. Shorter acute care lengths of stay often leave discharged patients requiring continued skilled care needs, medical surveillance and increased RN oversight/education.

So the question remains: What level of care is appropriate for a specific patient at discharge? That question must be considered over an etiologic diagnosis alone and site-neutral payment, even if it just begins with limited orthopedic diagnoses.

There are statistics that suggest the acuity and readiness of patients to learn and manage residual medical issues may have required more than the level of care provided at a SNF. High rates of return to acute care within 30 days is a problem being tackled as we speak in all venues of care, but particularly in SNFs where up to one in every five Medicare patients fit into that statistic.

Managing complexity and acuity may take longer than an acute hospital stay has enabled and/or patients may have accessed a ‘lesser level of care’ too soon. Although that level may be appropriate for a large number of discharges, considering all impairments, should conditions that require readmissions to an acute care facility, whether the primary diagnosis was orthopedic or medical, be reserved for PAC with greater physician/RN oversight?

There are many patients who can and are safely treated with the resources presently available in the SNF environment. Clinical staff that take the patient’s best interest into consideration know that matching resources based on the name of an etiologic condition alone isn’t practical. Physician care and RN availability and oversight have long been overlooked to help in determining the correct post-acute care options; resulting simpler guidelines such as: Was there a 3 midnight stay and bed available to guide the discharge decision?

As less access to IRFs occurred with diminished utilization of lower CMG levels ‘XX01’ CMG’s (patients whose motor function is 40 percent impaired as compared to 50 percent or more in IRF), and with an acute care push to decrease length of stay by directing patients to ‘lesser levels of care’, growth in post-acute care facilities and services exploded. Matching Medicare beneficiaries’ needs with required resources was not always given top consideration. Instead, ease of access may have guided discharge decisions.

This chart published in a MedPAC report from the CMS Office of the Actuary paints the picture of post-acute care growth. Clearly, IRFs and LTACHs have remained the most stable.



This growth then increased cost and payments per day to SNFs which, by and large (70 percent of the more than 15,000 SNFs per MedPAC), are operated by for-profit entities.


One would agree that despite the volume of patients being discharged from acute care, regulatory changes for directing patients away from an IRF level of care were successful.

Medicare beneficiaries were specifically steered to ‘lesser levels of care’, creating greater needs for growth in SNFs. The ability to manage high needs rehabilitation patients also increased.  Medical complexity and the need for physician and RN oversight were considered less important during discharge with the emphasis on ‘rehabilitation’ instead. Higher nursing acuity and rehabilitation therapy minutes increased as SNFs grew in volume.


Was directing care toward SNFs always more desirable? A comment made in a proposed rule to Medicare noted that joint replacement and orthopedic type patients could all be treated at the SNF level of care. CMS officials pointed out that this was not always in the best interest of the  beneficiary when they made this comment in the Federal Register of the SNF Final Rule that particular year.


Despite that comment, regulations changed for IRF access that continued to question medical necessity. Even when regulatory guidelines are followed, Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs), in hindsight, may still question whether the care provided ‘could have been’ offered in a SNF setting instead.

IRFs met with Washington D.C., lawmakers in 2007, to discuss that the changes in IRF access to care were being threatened. They went on to say the best interest of the patient was not always considered, given harsher guidelines and retrospective denial activity, even when the best outcomes were achieved by the patient with discharge plans being met.

Facilities do not have time, money or resources to defend denials just because ‘a lesser level of care’ MAY HAVE been more appropriate. By migrating more patients away from an IRF, one could argue higher medical oversight and compromised patient safety.

On the CMS SNF compare website, it notes that on a national level, SNFs provide, on average, less than one hour of RN care per resident, per day, or 50 minutes; an increase of two minutes since the last quarter of 48 minutes. ( The example below removed therapy minutes as not all residents receive therapy. We’ve utilized Arizona as the place of residence.)


Rehabilitation units often provide 4-8 times as much RN hours per patient day. What is to compare? How do you neutralize those costs and benefits in a retrospective look at actual patients treated in an IRF? Maybe we shouldn’t. Instead, maybe we should screen all patients appropriately and direct them to the correct resources, allowing far greater CMG levels to be accessed than are currently represented in CMGs (HIPPS billing codes) for IRFs.


Although some of these ‘snapshots’ may be taken out of context of the full report, the comments and graphs provide information that cannot be overlooked in the decisions of patient placement. Lawmakers cannot be given the impression that site-neutral resources/care existed in the timeframe the study data was compared.

Let IRFs admit the entire spectrum of possible CMS IRF PPS CMGs to enable improved Medicare beneficiary access. Making certain retrospective denials cannot occur based on a ‘could have had a lesser level of care argument’ and uphold physician validation of medical necessity in the pre-admission assessment and post -admission evaluations that serve as certification statements to access a rehabilitation level of care.

Applying site-neutral payment lacks real insight into regulatory realities that have placed IRF access and costs where they are today. Why continue to support more SNF PAC beds when regulations have forced most IRFs to be at 60-70% capacity or less? Tell this story to your lawmakers! Do not support site-neutral payment with only a portion of the IRF’s story being told.

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