Good News! 75% rule not implemented

[Louisville04]

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I got this email from the AAPMR:

Huge Win for Physiatrists - A Permanent Fix on Medicare's "75% Rule"
The American Academy of Physical Medicine and Rehabilitation successfully advocated for legislation approved by the House and Senate that will permanently freeze implementation of the "75% Rule" at the 60% level. The bill allows comorbid conditions to continue to count toward meeting the rule's threshold. Additionally, the bill requires that the Department of Health and Human Services study beneficiary access to inpatient rehabilitation services and make recommendations for classifying inpatient rehabilitation hospitals and units. While the Academy works toward the long-term goal of passing legislation that will remove admissions quotas and return the physiatrist to the position of freely determining what type of rehabilitation is medically necessary for any given patient, the Academy supports the above provisions as an intermediate step in improving access to acute comprehensive rehabilitation for people with disabilities. This provision constitutes a huge victory for the specialty!

 

[SSdoc33]

I definitely do believe that patients will benefit by not having the 75% rule implemented b/c it allows more appropriate patients for inpatient rehab, and I do see the need for that. however.......


as a solely outpatient physiatrist, how does this benefit me? in fact, i would argue that it will have a detrimental effect on the long-term practice of outpatient physical medicine. the "old school" of inpatient rehab will continue to put money and resources into developing inpatient-based residency programs. fewer resources and jobs will be available in academia for outpatient physiatrists. its great for the patients, great for the old guard of dinosaurs practicing rehabilitation (my apologies to those who make this their livelihood), but remind me how this will help the direction of PM&R. this will stunt the growth of where physiatry has been moving --outpatient sports, spine, and pain and sway us back to the old mediocrity of inpatient rehabilitation. whoopiee!!!!!

 

[drusso]

Actually, it is good for the whole specialty as preserves PM&R's presence in the hospital scene. Alot of patients enter "the post-acute care continuum" in the hospital. Your inpatient colleagues will be referring patient to you for outpatient MSK/pain/EMG/rehab issues.

Those polytrauma patients, SCI patients, TBI patients, etc all eventually develop acute and chronic musculoskeletal disorders and/or chronic pain. It also means that after grandma falls and breaks her hip she doesn't have to go languish in a nursing home getting unsupervised PT and being taken care of by nursing assistants making $11.00/hr. The population is aging and rehab services and utilization are set to sky-rocket. Physiatrists need to be there to lead (not follow).

Inpatient and outpatient physiatrists win.

 

[delicatefade]

Is there a trend of thought that inpt rehab is not needed or did I miss something somewhere?

 

[SSdoc33]

i think everyone agrees that inpatient rehab is "needed", but there is a train of thought that that is not the best direction for our specialty to take.

it seems that the outpatient MSK problems from the post-acute side is a tiny fraction of what an outpatient physiatrist typically sees. maybe in an academic center you'd get more spill over, but how many post-strokes with back pain does a private practice physiatrist in a neurosurgery or ortho group see?

 

[BLAZE2000]

This is great for both inpatient and outpatient physiatrists, as well as the general community. Of course, this increases the amount of eligible inpatients for IP rehab. Also, this gives OP physiatrists more options, that is, if OP physiatrists are still willing to do IP work. Now, you don't have to be a slave to your referrel source. e.g. now you don't have to feel pressure to call a radiculopathy on EMG for fear of not getting any more referrels from that neurosurgeon. You can always do IP!!!!

 

[SSdoc33]

You can always do IP!!!!

no %#$@#^ way.

 

[SCIronMike]

That piece of legislation also freezes the market basket update factor at 0% through the 2009 fiscal year.

 

[SCIronMike]

Specifically.....

Payments for inpatient rehabilitation facility (IRF) services. Permanently freezes the inpatient rehabilitation services compliance threshold at 60 percent, effective for cost reporting periods starting July 1, 2006, and allows comorbid conditions to count toward this threshold. Sets the market basket update factor at 0 percent from April 1, 2008 through fiscal 2009. Requires the secretary to study beneficiary access to inpatient rehabilitation services and care at IRFs and to make recommendations for classifying inpatient rehabilitation facility hospitals and units.

 

[buddy 2004]

Does anyone know how exactly this got passed, just for future reference? I know that there was some rehab-friendly pork attached to the failed SCHIP legislation earlier this year, but I had not heard much about this one.

 

[drusso]

It seems that the outpatient MSK problems from the post-acute side is a tiny fraction of what an outpatient physiatrist typically sees. maybe in an academic center you'd get more spill over, but how many post-strokes with back pain does a private practice physiatrist in a neurosurgery or ortho group see?

But it is only because the typical outpatient MSK/pain physiatry practices don't go after these patients. Believe me, the potential is huge. How many post-stroke or SCI patients develop a component of central pain, CRPS, painful contractures, simple MSK overuse injuries, etc. These issues are readily addressed with interventional treatments.

*MOST* anesthesia-trained pain physicians are not as savvy about detecting and managing these issues in this population as are physiatry-trained pain physicians. It's not rocket science, it's just a consequence of differences in base training.

If you're a interventional physiatrist you're cutting yourself short by not seeing these patients. Many will have facet-pain, SI-Joint pain, spasticity requiring botox, baclofen trials, vert compression fractures, etc. By treating these problems, *AND* updating their wheel-chair prescription, adapative equipment, etc you really create a niche for yourself.

 

[ShrikeMD]

My reading of this legislative victory doesn't get me too excited. Unless there is something I am missing, freezing at "60%" is more of a boon to rehab hospitals/units than it is to patients, clinicians or the specialty.

The "75% rule" should have been called the "0% rule", since many of the third-party contractors/fiscal intermediaries that Medicare uses to review rehab claims on these patients were denying payment for diagnoses that aren't "included" in the list required by IRFs to maintain at 75%. A rehab unit or hospital may lose its IRF status if the prevalence of "uncovered" diagnoses were too high, but in my region of the country, the units couldn't take these patients because Medicare wasn't paying for rehab for them anyway. Gross regional discrepancies in access to inpatient rehabilitation were being created because of the fiscal intermediaries latitude in interpretation of Medicare guidelines regarding what Medicare will pay for. No Medicare coverage=no money=no access for the patient.

Coverage of the diagnoses/access to rehab is the bigger issue, NOT the maintenance of IRF status for a rehab hospital or a relaxation in the guidelines for the diagnostic mix. When the issue of coverage and access denial are addressed, THEN I may celebrate...after the checks clear. For now, please pass some limes for my club soda.