key: cord-0841972-h5y7ffzb
authors: Meythaler, Jay
title: Proposed Changes to the Inpatient Services for the Disabled in the United States Post COVID-19: Editorial
date: 2020-05-11
journal: Arch Phys Med Rehabil
DOI: 10.1016/j.apmr.2020.05.001
sha: 3397f2b4d50005357545b5e6d28a91b8b6640626
doc_id: 841972
cord_uid: h5y7ffzb

nan

Editorial 6

Recently the Centers for Medicare and Medicaid Services (CMS) proposed a series of 7 regulations and guidance changing the amount and definitions of skilled medical care, the 8 intensity of therapy as well as the diagnostic criteria for patients admitted to inpatient 9 rehabilitation facilities (IRFs). [1] [2] [3] These proposed regulations threaten to diminish the amount 10 and the quality of care provided to people with disabilities, while also increasing expenditures 11 for their care. [1] [2] [3] Below are a summary of these changes and their potential impacts. 12

In 2019 before the COVID-19 crisis, CMS removed requirement for specialized training or 14 specific experience to qualify as a rehabilitation physician allowing the qualifications to be set by 15 each hospital. 1 16 17 At the beginning of the COVID-19 pandemic, CMS moved to reduce additional requirements so 18 that patients could be more quickly transferred to an IRF via emergency guidance. 2 CMS also 19 temporarily waived the intensity of therapy treatment as well as any pro-rata prioritization for 20 CMS defined rehabilitation 13 diagnostic categories, the so called 60% rule. 2 These changes will 21 affect the utilization of IRF services during the time of the waiver. 2 CMS has already placed into 22 question the intensity of therapy by removing the 3-hour rule with a much more broad 23 definition. 4 The new guidance does not sufficiently differentiate the intensity and specificity for 24 therapy in an IRF from the guidance for subacute therapy in a skilled nursing facility (nursing 25 home) following the emergency guidance. 2-5 26 27 Less than a month later, CMS proposed new regulations that will allow non-physician providers 28 such as physician assistants, nurse practitioners, and clinical nurse specialists to perform duties 29 currently reserved for rehabilitation physicians serving IRF patients. 3 These proposed changes 3 30 are a significant contradiction of the 2019 Federal regulations where CMS stated that "we do not 31 believe that merely clarifying our existing policy would reduce quality of care. The regulation will continue to require a rehabilitation physician to be a licensed physician with specialized training and experience in inpatient rehabilitation. We are not lowering these requirements." 1 34

Additionally, there is little in the way of guidance with regards to the training or specified 35 experience for these non-physician providers in the proposed regulation. 3 States. However, the financial savings from utilizing less costly and less well trained or 42 experienced staff may be more than offset by increased costs due to reductions in the quality of 43 IRF care. These proposed regulatory changes will not supersede local state standards and 44 individual hospital guidelines that may be stricter. 45 46 CMS will continue to utilize a relative weighting of diagnostic factors to account for a patient's 47 clinical characteristics and expected resource needs as defined by the current prospective 48 payment system (PPS) and case-mix groups (CMGs) methodology. 3 However, retrospective data 49 does not take into account that there may have been statistical bias with regards to the current 50 PPS CMG data due to the previous application of the training and experience requirements, the 3 51 hour rule and the 60% rule. 2-4 The potential effects on rehabilitation quality and cost will not 52 become evident until new data become available for analysis. Differentiating which factor may 53 be significant, considering the rapidity of these changes, will be difficult. 54 55 Furthermore, CMS has proposed increasing reimbursement by 2.9% for IRFs, 3 creating a 56 financial windfall to IRF owners. 3 IRF care is already reimbursed at 2.5 times the national 57 average for CMS reimbursement compared to standard acute care hospital admissions. 7 These 58 proposed regulations create a significant incentive to provide the minimum required services for 59 the maximum reimbursement. 6 For-profit IRFs already provide over 50% of IRF care and must 60 answer to their investors creating an additional incentive to support the regulatory changes. can be conveniently forwarded at the following web site. 77 (https://www.federalregister.gov/documents/2020/04/21/2020-08359/medicare-program-78 inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal). 3 79

Medicare Program; Inpatient Rehabilitation Facility (IRF)

Medicare Program; Inpatient Rehabilitation Facility Prospective

Payment System for Federal Fiscal Year 2021 AGENCY: Centers for Medicare &

Medicaid Services (CMS), HHS. ACTION: Proposed rule. 42 CFR Part 412

RIN 0938-AU05

Clarification of Instructions Regarding the Intensive Level of Rehabilitation 100 Therapy services Requirements

Legal Information Institute. 42 CFR § 409.33 -Examples of skilled nursing and 105 rehabilitation services

Medicare Trust Fund is set to run out in 2026, but that doesn't account articles/revenue-quality/medicare-trust-fund-is-set-to-run-out

National Health Expenditure 9

pdf 126 127 Acknowledgements: I appreciate the editing and helpful input by