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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, January 31, 2012 Posted in: Inpatient Rehab

For those in inpatient rehabilitation, the 75% rule (now 60%) has long been a discussion to validate and uphold an exemption status that defines your ability to provide special services at the intensity to earn a designation called ”Inpatient Rehabilitation” whether you are free standing (IRF) or a unit (IRU). IRFs, having fought the long, hard battle with Congress, won a “permanent” percentage in the MMSEA Act of 2007. Now permanency is being challenged in the newest proposal, “The President’s Plan for Economic Growth and Deficit Reduction.”

A percent classification system is an arbitrary definition of status. Do facilities capable of caring for patients needing rehabilitation need to waste time defending status of a specific type of disability if  the real impairment is inability to return to the community shared by all? If a patient cannot go home after an inpatient acute stay (IPPS), regardless of the condition, shouldn’t  the patient have access to rehabilitation specialty care?  What are the important statistics?  I feel outcomes in the face of adversity are the numbers to watch AND REWARD! 

Given IRF/IRUs  present reimbursement is leveled around a 1.0 case mix index; and given those numbers are correlated now to an average length of stay, we have some historical benchmarks.  We should develop an effectiveness and efficiency ratio for each rehabilitation provider.   Make that NUMBER the number to watch and be rewarded to maintain status as an inpatient rehabilitation provider.  These are the numbers that distinguish the good from the great.   Allow the efficiency ratio to define market basket increase or decrease.   Take into consideration the total percent of population treated in hard to return home conditions such as SCI, TBI and high level CVA so that those hard to treat conditions are weighted even greater for successes in return to community.  Reward those providers that do not shy away from the toughest conditions. Include in the ratio a reduction if patients return to acute within 30 days.  Reductions should be shared by a specific percent for all inpatient providers of care; not just the acute hospital.  This is a more tangible definition of  ”accountable care” and improved access.

If we made the numbers to watch acuity and percent discharge to home;  the focus is now on outcomes and not arbitrary access.  Any diagnosis that cannot return home because of medical and functional impairment will be given an equal chance to access care with the right motivation and intentions – to get home expeditiously.  Given those conditions, the better facilities get greater compensation. Everyone strives to be best!  Stop wasting time; work toward the appropriate resources to get the desired results and reimburse based on those results given the level of acuity presented.

A percent admission based on a diagnosis and not the resultant impairment does not align with World Health Organization initiatives. Let’s change it!  The only question is can the patient return to the community, yes or no?  If no, determine resource needs, weight payment and bonus expeditious long standing outcomes.  Is it pay for performance?  Absolutely.

Percent compliant admissions that define a level of care is discriminatory to any patient that cannot return home based on their functional capability.  Impairment rather than diagnosis is the defining factor.   Returning to a 75% rule is NOT the answer to deficit reduction when impairment will not allow a patient to go home.   Rewarding quick access and payment commensurate to outcomes based on acuity is the answer and fits more closely with Medicare’s newest focus.

Write your congressional leaders and tell them why percentage access rules are incomprehensible to individual rights. After all, someday it could be themselves or a relative they vote access discrimination upon.  IRFs/IRUs cannot and should not return to a 75% rule to justify existence as a specialty rehab provider.  Outcomes given acuity should be  the marker.  Educate and lead leaders.  Be a voice for your patients.  Let’s think out-of the 75% rehab rule box.

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