Acute Medical Rehabilitation Surviving Health Care Reform

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1 Acute Medical Rehabilitation Surviving Health Care Reform Kathleen C. Yosko, RN, MS, MBA President & CEO Marianjoy Rehabilitation & Clinics Wheaton, Illinois Marianjoy Rehabilitation and Clinics 2 1

2 Acute Medical Rehabilitation Acute rehabilitation is a medically-based, multidisciplinary approach for the treatment of stroke, brain injury, spinal cord injury, amputation, neuromuscular disorders, and musculoskeletal and orthopedic conditions including joint replacement all of which may impact physical function and mobility, speech and cognition, behavior and emotions, and personal independence 3 Post Acute Medicare Spending Increase of 9% / Year Increase of 6% / Year * Higher than growth in overall healthcare costs * Medpac, June

3 Patient Protection and Affordable Care Act of 2010 Requires Medicare experiment with bundled payment for a hospitalization plus post acute care. Episode 3 days prior to hospitalization for a condition plus 30 days post-hospital discharge. Incentives and disincentives for providers and patients. i.e., readmissions to Acute Care; potential reduction in services to patients 5 The Underlying Philosophy of Most Rehabilitation Providers Good people doing good things for people with special needs The Current Status of Medical Rehabilitation Medical Rehabilitation has been under siege for the past nine years, as we attempt to admit patients from acute care, who tend to be arriving at our facilities sicker and sooner. 6 3

4 Issues Medical Rehabilitation has Faced for the Past 9 Years New Prospective Payment system for Inpatient Rehabilitation % (60%) Rule The fix for 75% Rule Market Basket Freeze 2007 and 2008 May 7, 2004 Medical necessity audits Care Tool Pilot Project 2011 Reporting Out HCFA Rule 85-2 Medical Necessity Criteria rescinded Implementation of New Medical Necessity criteria for discharges January 1, 2010 and beyond 7 75% (60%) Rule 93% of all hospitals and units were found to be non-compliant Phase-in period for compliance 50% beginning 2005 Presumptive compliance American Medical Rehabilitation Providers (AMRPA) unable to effect Rule change - May 7,

5 The Rehabilitation Stew of Medicare Post Acute Providers Long Term Care s LTCHS Focus on medically complex patients LOS < 25 days MS.LTC-DRG s Medical severity Long Term Care 35,000/per discharge Number of LTACHS 278 in 2001; 432 in 2009 Current moratorium 9 The Rehabilitation Stew of Medicare Post Acute Providers continued Inpatient Rehabilitation Facility - IRFs Patient meets medical necessity criteria for compliance threshold for facility Requires 24 hour nursing care Needs to tolerate 3 hours of therapy a day 60% required 20 Rehabilitation Impairment Groups qualifying diagnosis; however CMS pays for 100 CMG s under PPS $16,700 per discharge 10 5

6 RIC 2&3 BI RIC 4&5 SCI RIC 6 Neuro RIC 7 Fx LE May 16, 2003 Rule Impact of 75% rule if applied per CMS Insurance Referral RIC 20 Part of Misc. RIC 1 Stroke RIC 11 Amp Other RIC 17&18 Narrowed Multi Trauma RIC 13 Partial Rheumatoid Arthritis RIC 10 Amputation Physician Referral RIC 19 Guillian Barre Acute Referral Determined Patient need for Level Acute Rehabilitation Services IRF-PAI Patient 5 Patient 4 Patient 3 Patient 2 Patient 1 RIC 20 Part of Misc RIC 16 Pain RIC 14 Cardiac Direct Referral for IE ACCESS DENIED RIC 9 Partial Oth Ortho RIC 15 Pulmonary RIC 8 65% Joint Repl Case Mgmt Referral RIC 12 Osteo 11 Arthritis Partial The Rehabilitation Stew of Medicare Post Acute Providers continued Skilled Nursing Facility - Short term skilled inpatient nursing or rehabilitation services after 3-day stay inpatient hospital stay Per diem reimbursement $275 - $300 per day, approximately $12,000 per discharge RUGs resource utilization groups 66 categories based on diagnosis, therapy and service use 12 6

7 The Rehabilitation Stew of Medicare Post Acute Providers continued Outpatient Rehabilitation Therapy PT, OT, Speech Goals need to be restorative and not maintenance Numerous hospital and non hospital-based providers -based not subject to therapy cap Non hospital-based providers subject to therapy caps approximately 100 units or 25 hours = $1,870 per year/per patient reimbursed to provider by Medicare 13 The Rehabilitation Stew of Medicare Post Acute Providers continued Home Health Home-bound need for skilled nursing care/part-time intermittent Skilled nursing, PT, OT, Speech, Social Work and Health Aid 60-day episode Payment based on HHRG (Home Health Resource Group) 153 categories based on clinical/functional status/service use 14 7

8 Problems All providers not held to a common standard i.e., Outcome criteria Different coverage criteria, facility requirements and payment methodologies for each level of care Lack of coordination between settings Lack of consistent standard of admission criteria/functional outcome measures 15 Patient Revised 12/01/09 KEY Nursing Home Acute Care Current Delivery System ASSISTED LIVING LONG TERM HOSPITAL ACUTE HOSPITAL/UNIT HOSPITAL Nursing Home ASSISTED LIVING ACUTE HOSPITAL/UNIT Nursing Home Nursing Home ACUTE HOSPITAL/UNIT Long Term Long Term ACUTE ASSISTED LIVING ASSISTED LIVING Nursing Home 8

9 Continuing Care Concept (CCH) Patient Acute Care Readmissions CCH (IRF, LTCH, Based Levels of Care) FREESTANDING FREESTANDING Case Mix Adjusted CCH Rate CCH Site Neutral Virtual or Real CCH Bundle For Readmissions: Shared Payment Reduction Revised 12/01/09 Copyright 2009, AMRPA, Washington, DC 17 ASSISTED LIVING CCH Creates a Bundled PAC Episode for Payment Reform Patient Acute Care Readmission Policy Episode of Care for Payment Continuing Care Nursing Home/Long Term Care/ Assisted Living ASSISTED LIVING Case Mix Adjusted CCH Rate CCH Site Neutral Virtual or Real CCH Bundle For Readmissions: Shared Payment Reduction NURSING / ASSISTED LIVING Revised 12/01/09 Copyright 2009, AMRPA, Washington, DC 18 9

10 Care Tool Project Care Tool Project Continuing Assessment Record and Evaluation Instrument CMS Deficit Reduction Act 2005 Mandate developed to measure clinical and functional status of patient upon acute hospital discharge and post acute care admission and discharge 19 Care Tool Project continued 3 year pilot project ends 2011 Collects information on medical, functional, cognitive impairment, social/environmental factors Attempts to measure severity differences within medical conditions/predict outcomes Movement by CMS to one payment system 20 10

11 Acute Care Providers Will Need to Work Closely With Rehabilitation Providers Balance Required Needs to be protection for patients and outcomes Reduce cost/promote quality 21 11

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