Now that CMS has released the proposed rule, what specific impact has it had on the various Rehabilitation Impairment Categories (RICs)?
Customarily, inpatient rehabilitation facilities treat the highest volume of patients in stroke, fracture of the lower extremity, replacement of the lower extremity, miscellaneous, and neurological conditions. On first glance, it looks as though there is a windfall toward improved realized payment across the board. The devil is in-the-detail however, as to what in total reflects actual payment? It is critical for each facility to weigh “payment” against CMI and facility adjusters to define actualized payment; unique to their facility. This and historical volumes by CMG will provide some evidence of what to expect individually.
Standard payment rate will increase by $668 ($13,860 to $14,528) however, the attempt to maintain budget neutrality through the IRF facility adjusters; labor share, market basket values, LIP, teaching status etc., will have marked impact on real paid dollars.
In a quick PDF file-search of the word “neutral” in the proposed regulations, there are nearly 50 references reiterating the same facts for how neutral budget will control payment to IRFs. Facilities must study how these changes affect themselves, given budget neutral factors and the volumes for the various case mix groups.
Case mix index (CMI) change is reflected to the ten-thousandths place with relative weight changes ranging from a negative 0.5271 (C1803); a tier 2 major multiple trauma with spinal or brain injury – low motor score, to an increase of 1.0503 (B0405); a tier 1 co-morbidity traumatic spinal cord injury patient. These ranges reflect the greatest variance from previous year regulations with a payment swing of $5,820 less to $17,120 more per case.
Whereas miscellaneous and joint replacement CMGs have almost all shown improvements in each tier level reimbursed, there are reducing payments in tier 1 stroke, neurological and lower extremity fracture patients at various levels.
How will reductions in tier 1 cases influence future admissions to IRFs? Can high resource demand with lessening payments be realistic to manage that population? Is there a ceiling to just how involved a case should be to warrant cost effective care and still be appropriate for the rigors and demands of interdisciplinary IRF level services? Has there been trends that have demonstrated to CMS that these types of patients generally take longer or have less successful outcomes with the rigors an IRF schedule demands? Is it all about cost report averages showing our margins or volumes became too high in these categories that seem more easily argued as meeting medical complexity?
Finally, will these reductions steer facilities toward realistically accepting those patients who are less acutely ill but stand greater promise to benefit from an IRF level of care? Patients that are appropriate because they demand hour-per-patient-day clinical contact, greater than a published average for what can be expected in a SNF level of care in their market. What effects do you think this rule will have?
One thing is for sure, margins are getting tighter and the management of effective, efficient care must follow.
Click on the following links to see how the 2012 proposed rule will affect the respective RIC
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