Hospitals realized that operating a rehabilitation unit within the confines of the DRG system for acute care afforded the ability to recover significant costs with the DRG exempt beds. Many hospitals today still operate their rehab units with the expectation they will perform much like other programs, units or service lines within a hospital. These facilities are becoming increasingly aware that compliance with the prospective payment rules differs significantly. Inpatient rehabilitation facility beds paid under the Medicare Prospective Payment System require demonstration of the ability to deliver a rehabilitation care process with evidence of compliance with these unique expectations. The process requirements are the same regardless of the number of rehab beds in play. One or one hundred beds, it requires the same process to attend to the expectations of the inpatient rehabilitation hospital.
In 2010, CMS described these expectations in greater detail with auditable accountability for demonstration of compliance. Now known as the “2010 Rules,” emphasis on the process of rehabilitation is mandated and for many inpatient rehabilitation providers, this meant doing things differently than before and perhaps needing more resources to do it. And along came additional costs.
This is apparent when trying to assign nursing hour requirements to patients receiving inpatient rehabilitation. It is not only the nursing procedures or services to be applied that total the nursing requirement, but also the care process required to deliver them (i.e., problem oriented, goal directed, coordinated and delivered with an interdisciplinary team.) Nurses attending to the process require additional time to accomplish these requirements. The costs associated with delivery of the rehabilitation care model are different and require specific analysis and management. Somewhere between the one bed and one hundred beds hospital is the point where the rehabilitation process just doesn’t have sufficient volume to support the associated costs.
The “2010 Rules” have not changed the expectations of rehabilitation care, but the accountability to demonstrate the process of rehabilitation is followed, creates additional pressure for hospitals to differentiate care on their rehab units. Some have not yet come to understand that the act of rehabilitating patients requires more than the availability of a nurse, a therapist and a doctor.
The number of hospital based rehabilitation units decreased by 10 facilities between 2008 and 2009. The additional pressure applied by the requirements of the “2010 Rules” will most likely accelerate closure of smaller units who will find difficulty complying with the rehab process requirements. For the rest, managing the process requirements efficiently will be the key to survival, unless of course a hospital chooses to subsidize the difference.