BBBMD's synopsis is an awesome compilation of the current state of of affairs vis a vis the 75% rule. I attended the AAPM&R billing and coding workshop in late July, and Dr. Kurt Hoppe, Chair of the Health Policy and Legislation (HP&L) Committee, spoke at length on this very topic. He also handed out a copy of the the final rule, which was published in the Federal Register by CMS on May 7th - you can read it at
http://www.aapmr.org/zdocs/hpl/rehab.pdf.
So here is the deal - inpatient rehab is the most expensive bed in the hospital, more than on acute, and far more than SNF. To date, despite all our nashing of teeth, there is no research that shows total joint patients do any better in an IRF (Intensive Rehab Facility) than they do in SNF, where the reimbursement is rediculously low. So approach #1, in my simple minded way of thinking, would be DO THE RESEARCH! Who better than a bunch of students and residents, who want to be published anyway, to get this done! I have spoken with my chaiman, you should speak to the movers and shakers in your institution, and we should not just bemoan our fate, we should DO something about it.
On that same activism point, there is a piece of legislation called the Lowey-Wamp 75% Rule Amendment which would impose a statutory moratorium on enforcement of the 75% Rule, and would delay implementation until an Institute of Medicine (IoM) study is completed on the issue. If passed, this amendment would ensure that future policymaking related to the 75% Rule and medical necessity criteria are based on a strong clinical foundation
This bill is before the House Rules Committee, which determines the procedures by which the House will consider specific legislation, and helps to ensure that the legislation is consistent with the House rules. The Rules Committee?s procedures permit any committee chairman the prerogative to request certain provisions of the bill be removed if those provisions undertake a matter that is within the jurisdiction of that chairman?s committee. In this regard, the AAPM&R has learned that Rep. Bill Thomas (R-CA), Chairman of the House Ways and Means Committee, may seek to have all or a portion of the language included in the Lowey-Wamp Amendment removed. It is likely that the House will not take up the Labor/HHS Appropriations bill until some time in September, so now is the time to contact your Congressperson, but specifically Chairman Thomas' offices:
2208 Rayburn House Office Building
Washington, DC 20515
Ph. 202-225-2915
Fx. 202-225-8798
4100 Empire Drive, Suite 150
Bakersfield, California 93309
Ph. 661-327-3611
Fx. 661-637-0867
5805 Capistrano Avenue, Suite C
Atascadero, CA 93422
Ph. 805-461-1034 - North County
Ph. 805-549-0390 - South County
Fx. 805-461-1323
Oh, and in case you think we are alone in our fight, there are 22 organizations who are lobbying on our behalf:
American Academy of Neurology
American Academy of Physical Medicine and Rehabilitation
American Association of Hip and Knee Surgeons
American Association of Mental ******ation
American Association of People with Disabilities
American Congress of Community Supports and Employment Services
American Congress of Rehabilitation Medicine
American Foundation for the Blind
American Hospital Association
American Medical Rehabilitation Providers Association
American Occupational Therapy Association
American Physical Therapy Association
American Speech Language Hearing Association
American Therapeutic Recreation Association
Association of Academic Physiatrists
Brain Injury Association of America
Catholic Health Association of the United States
Disability Service Providers of America
Easter Seals
Federation of American Hospitals
Halftheplanet Foundation
National Association of Protection and Advocacy Systems
National Association of Social Workers
National Recreation and Park Association
Paralyzed Veterans of America
Rehabilitation Engineering and Assistive Technology Society of North America
The Arc of the United States
United Cerebral Palsy
Why the Cardiologists, Pulmonologists, and Orthopaedic Surgeons are not on board is not entirely clear to me
If you are a geek like me, and actually want to READ the text of the Amendment before you decide to support it actively, I have pasted it below for your enjoyment:
AMENDMENT TO LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION APPROPRIATIONS BILL, 2005
OFFERED BY MRS. LOWEY (for herself and Mr. Wamp)
Page 64, after line 25, insert the following new sections:
SEC. 221. LIMITATION ON USE OF FUNDS; STUDY.
(a) LIMITATION ON FUNDS.?Notwithstanding any other provision of law, none of the funds appropriated by this Act or any other Act may be expended by the Secretary of Health and Human Services or by a medicare
fiscal intermediary or administrative contractor?
(1) to apply the criteria (commonly known as the ??75 percent rule??) that are used to determine whether a hospital or unit of a hospital is an inpatient rehabilitation facility (as defined in Department of Health and Human Services, Centers for Medicare and Medicaid Services, ??Medicare Program; Final Rule; Changes to the Criteria for Being Classified as an Inpatient Rehabilitation Facility??, 69 Federal Register 25751 et seq. (May 7, 2004),
and any accompanying CMS Manual System Transmittals (including, but not limited to, H.L.C.221 and any change request pursuant to such rule)
for purposes of the medicare program;
(2) to compile facility data pertaining to compliance with such 75 percent rule or enforce such rule; or
(3) to utilize or apply any existing or new local medical review policy, local coverage determination, or national coverage determination with respect to
medical necessity standards for inpatient rehabilitation facilities under the medicare program; until the date that is 9 months after the date on which
the report required by subsection (b)(3) is transmitted to the Secretary and the Congress.
(b) STUDY AND REPORT.?(1) The Secretary of Health and Human Services shall contract with the Institute of Medicine of the National Academy of Sciences to study and make recommendations (and submit a report
under paragraph (3)) on?
(A) a clinical consensus on how to modernize the medicare criteria used to distinguish an inpatient rehabilitation facility from an acute care hospital and other providers of intensive medical rehabilitation; and
(B) the appropriate medical necessity criteria for determining clinical appropriateness of inpatient rehabilitation facility admissions, with due consideration being given to chapter 1, section 110 of the Medicare Benefit Policy Manual, the current capabilities of treatments and modalities performed by acute and post-acute providers, and the combined medical and functional needs of patients.
(2) Under such contract the Institute shall use a panel that includes a multi-disciplinary group of expert researchers and clinicians in the field of medical rehabilitation.
(3) Under such contract the Institute shall submit a report to the Secretary and the Congress on the study and recommendations described in paragraph (1) not later than October 1, 2005.
Page 40, line 2, strike the period at the end and insert
the following:
Provided further, That the aggregate amount under this heading is hereby reduced by $9,000,000, such reduction shall be allocated among the programs and activities under this heading (including programs and activities for which amounts are specified under this heading) in such manner as the Administrator of the Centers for Medicare & Medicaid Services determines to be appropriate.
(Continued)
