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Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, November 14, 2013 Posted in: Acute Care Rehab

If you haven’t heard, there are many indications that the government is considering some ‘site neutral’ payments for the types of care provided under “rehabilitation services” without any consideration to the mandate of regulatory variation and/or cost differences of the sites providing the care.

Why? Because it is really difficult to discern by persons establishing such regulations that some orthopedic conditions and yes, even stroke, do not provide the same level of care in ‘post acute care’ venues such as an IRF or a skilled nursing home level of care. The MedPac review indicates that these two environments provide the same level of rehabilitation and should be paid similarly. How does that make you feel? (Most likely it depends what level of care you represent.) However, there are major differences not accounted for when considering that ‘just pricing’ should be equivalent.

Does this leave you scratching your head? There are MANY differences in the costs associated with, as well as the level of services demanded, between a SNF and an IRF level of care. Even IF the highest paid ultra high rehab category is 12 hours of therapy per week rather than 15 provided in an IRF level of care, what about the other differences? What about the vigilance of nursing staff and contact time with patients which is generally six to seven hours more per patient day in an IRF/U? What about the fact that a rehabilitation physician attends to the POC in person no less than three times per week and often five or more including weekly conferences versus the less aggressive weekly to monthly contact of physician services provided at a SNF? Compare nursing hours for yourself. Visit the Skilled Compare website and apply your zip code to review the RN compliment of staffing per resident per day in a few facilities near you, and then compare that to the generally five or more hours of IRF RN staffing compliment provided at an IRF/U.

These often highly medicated patients with multiple underlying co-morbid conditions must often relearn to care for themselves or with family assistance in generally less than a 15 day length of stay in an IRF. IRF/Us are paid by Medicare in ONE all inclusive PPS payment to cover those services. In a SNF, each day pulls in a prospective payment rate and often two to four MDS cycles of payment to cover the entire cost of the length of stay. More studies must demonstrate care cost analogies and outcomes efficacy but one cannot readily make the statement that a SNF level of care is ‘less costly’.

Add in the fact that patients treated in an IRF/U may be treated in less than a third of the average length of stay than a SNF level of care, with fewer readmissions to acute care within 30 days post discharge; and ultimately, the longevity of the outcomes show higher performance for those discharged from an IRF than those from a SNF. CMS themselves highlighted some differences in 2011 within the 2012 SNF regulations when a commenter to the proposed rule blindly stated the same level of services were provided more cost effectively in a SNF.

 

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n a recent campaign by the American Medical Rehabilitation Providers Association (AMRPA), they urged congressional leaders to sign a letter addressed to HHS Secretary Kathleen Sebelius urging her to reject the President’s proposals to establish site neutral payments for IRH/Us and SNFs and reinstate the 75 percent compliance threshold. They stated, “Rehabilitation hospitals and units (also known as inpatient rehabilitation facilities, or IRFs) provide highly-specialized medical rehabilitation care and services to Medicare beneficiaries and other patients recovering from debilitating injuries or illnesses that require intensive rehabilitation, constant nursing care, and medical management by a rehabilitation physician. IRF expenditures comprise a relatively small portion of Medicare’s overall budget – less than two percent. We are writing to express serious concerns about two proposals contained in President Obama’s FY14 Budget submission that will erode patients’ access to medical rehabilitation by returning to the “75 Percent Rule” and requiring payment parity between IRFs and skilled nursing facilities (SNFs) for certain conditions.”

AMRPA urges everyone to educate their congressional representatives about these disparities and to join them in their guidance to protect appropriate access to a rehabilitation level of care appropriate to every American.

Now, back to the reason for this post. MedPAC, the Medicare Payment Advisory Commission, an independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program, discussed site neutral payment in their monthly meeting Nov. 7th, 2013. They discussed the payments to IRF/U and SNFs for post acute care of certain conditions based on “beneficiary characteristics” (essentially primary diagnosis) rather than “the setting where services were furnished.” The minutes of this meeting will be posted shortly at the link provided. You should stay tuned to this topic! In some way it will become a step toward future payment reform and your comments and insight to the individuals listed in addition to your congressional leaders will be highly appreciated from the ‘inside looking out’ as to why conditions and costs are prohibitive to simply neutralizing payment unless that payment is highly indicative of the resources necessary to manage the plan of care effectively and efficiently.

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