Medicare
More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities Gao ID: GAO-05-825T June 16, 2005Medicare classifies inpatient rehabilitation facilities (IRF) using the "75 percent rule." If a facility can show that during a 12-month period at least 75 percent of its patients required intensive rehabilitation for 1 of 13 listed conditions, it may be classified as an IRF and paid at a higher rate than for less intensive rehabilitation in other settings. Because this difference can be substantial, it is important to classify IRFs correctly. GAO was asked to discuss issues relating to the classification of IRFs, and in April 2005 it issued a report, Medicare: More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities (GAO-05-366). For that report, GAO analyzed data on all Medicare patients (the majority of patients in IRFs) admitted to IRFs in fiscal year 2003, spoke to IRF medical directors, and had the Institute of Medicine (IOM) convene a meeting of experts to evaluate the use of a list of conditions in the 75 percent rule. This testimony is based on the April 2005 report.
As noted in the April 2005 report, GAO found that in fiscal year 2003 fewer than half of all IRF Medicare patients were admitted for having a primary condition on the list in the 75 percent rule. Almost half of all patients with conditions not on the list were admitted for orthopedic conditions, and among those the largest group was joint replacement patients. The experts IOM convened said that uncomplicated unilateral joint replacement patients rarely need to be admitted to an IRF, and GAO analysis suggested that relatively few of the Medicare unilateral joint replacement patients had comorbid conditions that suggested a possible need for the IRF level of services. Additionally, GAO found that only 6 percent of IRFs in fiscal year 2003 were able to meet a 75 percent threshold. GAO also found that IRFs varied in the criteria used to assess patients for admission, using patient characteristics such as functional status, as well as condition. The Centers for Medicare & Medicaid Services (CMS), working through its fiscal intermediaries, had not routinely reviewed IRF admission decisions to determine whether they were medically justified, although it reported that such reviews could be used to target problem areas. The experts IOM convened and other clinical and nonclinical experts GAO interviewed differed on whether conditions should be added to the list in the 75 percent rule. The experts IOM convened questioned the strength of the evidence for adding conditions to the list--finding the evidence for certain orthopedic conditions particularly weak--and some of them reported that little information was available on the need for inpatient rehabilitation for cardiac, transplant, pulmonary, or oncology patients. They called for further research to identify the types of patients that need inpatient rehabilitation and to understand the effectiveness of IRFs. There was general agreement among all the groups of experts interviewed that condition alone is insufficient for identifying appropriate types of patients for inpatient rehabilitation, since within any condition only a subgroup of patients require the level of services of an IRF, and that functional status should also be considered in addition to condition. GAO concluded that if condition alone is not sufficient for determining which types of patients are most appropriate for IRFs, more conditions should not be added to the list at the present time and the rule should be refined to clarify which types of patients should be in IRFs as opposed to another setting.
GAO-05-825T, Medicare: More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities
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Testimony:
Before the Subcommittee on Health, Committee on Ways and Means, House
of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 1:00 p.m. EDT:
Thursday, June 16, 2005:
Medicare:
More Specific Criteria Needed to Classify Inpatient Rehabilitation
Facilities:
Statement of Marjorie Kanof:
Managing Director, Health Care:
GAO-05-825T:
GAO Highlights:
Highlights of GAO-05-825T, a report before the Subcommittee on Health,
Committee on Ways and Means, House of Representatives:
Why GAO Did This Study:
Medicare classifies inpatient rehabilitation facilities (IRF) using the
’75 percent rule.“ If a facility can show that during a 12-month period
at least 75 percent of its patients required intensive rehabilitation
for 1 of 13 listed conditions, it may be classified as an IRF and paid
at a higher rate than for less intensive rehabilitation in other
settings. Because this difference can be substantial, it is important
to classify IRFs correctly. GAO was asked to discuss issues relating to
the classification of IRFs, and in April 2005 it issued a report,
Medicare: More Specific Criteria Needed to Classify Inpatient
Rehabilitation Facilities (GAO-05-366). For that report, GAO analyzed
data on all Medicare patients (the majority of patients in IRFs)
admitted to IRFs in fiscal year 2003, spoke to IRF medical directors,
and had the Institute of Medicine (IOM) convene a meeting of experts to
evaluate the use of a list of conditions in the 75 percent rule. This
testimony is based on the April 2005 report.
What GAO Found:
As noted in the April 2005 report, GAO found that in fiscal year 2003
fewer than half of all IRF Medicare patients were admitted for having a
primary condition on the list in the 75 percent rule. Almost half of
all patients with conditions not on the list were admitted for
orthopedic conditions, and among those the largest group was joint
replacement patients. The experts IOM convened said that uncomplicated
unilateral joint replacement patients rarely need to be admitted to an
IRF, and GAO analysis suggested that relatively few of the Medicare
unilateral joint replacement patients had comorbid conditions that
suggested a possible need for the IRF level of services. Additionally,
GAO found that only 6 percent of IRFs in fiscal year 2003 were able to
meet a 75 percent threshold.
GAO also found that IRFs varied in the criteria used to assess patients
for admission, using patient characteristics such as functional status,
as well as condition. The Centers for Medicare & Medicaid Services
(CMS), working through its fiscal intermediaries, had not routinely
reviewed IRF admission decisions to determine whether they were
medically justified, although it reported that such reviews could be
used to target problem areas.
The experts IOM convened and other clinical and nonclinical experts GAO
interviewed differed on whether conditions should be added to the list
in the 75 percent rule. The experts IOM convened questioned the
strength of the evidence for adding conditions to the list”finding the
evidence for certain orthopedic conditions particularly weak”and some
of them reported that little information was available on the need for
inpatient rehabilitation for cardiac, transplant, pulmonary, or
oncology patients. They called for further research to identify the
types of patients that need inpatient rehabilitation and to understand
the effectiveness of IRFs. There was general agreement among all the
groups of experts interviewed that condition alone is insufficient for
identifying appropriate types of patients for inpatient rehabilitation,
since within any condition only a subgroup of patients require the
level of services of an IRF, and that functional status should also be
considered in addition to condition.
GAO concluded that if condition alone is not sufficient for determining
which types of patients are most appropriate for IRFs, more conditions
should not be added to the list at the present time and the rule should
be refined to clarify which types of patients should be in IRFs as
opposed to another setting.
What GAO Recommends:
In its April 2005 report, GAO recommended that CMS take several
actions, including describing more thoroughly the subgroups of patients
within a condition that require IRF services, possibly using functional
status or other factors in addition to condition. CMS generally agreed
with the recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-05-825T.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marjorie Kanof at (202)
512-7114.
[End of section]
Madam Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss our report entitled Medicare:
More Specific Criteria Needed to Classify Inpatient Rehabilitation
Facilities,[Footnote 1] which was issued in April 2005. Over the past
decade, both the number of inpatient rehabilitation facilities
(IRF)[Footnote 2] and Medicare payments to these facilities have grown
steadily. In 2003, there were about 1,200 such facilities. Medicare
payments to IRFs grew from $2.8 billion in 1992 to an estimated $5.7
billion 2003 and are projected to grow to almost $9 billion per year by
2015.
Because patients treated at IRFs require more intensive rehabilitation
than is provided in other settings, such as an acute care hospital or a
skilled nursing facility (SNF),[Footnote 3] Medicare pays for treatment
at an IRF at a higher rate than it pays for treatment in other
settings. The difference in payment to IRFs and other settings can be
substantial, and so IRFs need to be correctly classified to be
distinguished from other settings in which less intensive
rehabilitation is provided.
To distinguish IRFs from other settings for payment purposes and to
ensure that Medicare patients needing less intensive services are not
in IRFs, the Centers for Medicare & Medicaid Services (CMS) relies on a
regulation commonly known as the "75 percent rule."[Footnote 4] This
rule states that if a facility can show that during a 12-month period
at least 75 percent of all its patients, including its Medicare
patients, required intensive rehabilitation services for the treatment
of at least 1 of the 13 conditions listed in the rule,[Footnote 5] it
may be classified as an IRF. The rule allows the remaining 25 percent
of patients to have other conditions not listed in the rule. IRFs are
required to assess patients prior to admission to ensure they require
the level of services provided in an IRF, and CMS is responsible for
evaluating the appropriateness of individual admissions after the
patient has been discharged through reviews for medical necessity
conducted under contract by its fiscal intermediaries.[Footnote 6] An
IRF that does not comply with the requirements of the 75 percent rule
may lose its classification as an IRF and therefore no longer be
eligible for payment by Medicare at a higher rate.[Footnote 7]
IRF compliance with the rule has been problematic, and some IRFs have
questioned the requirements of the rule. CMS data indicate that in 2002
only 13 percent of IRFs had at least 75 percent of patients in 1 of the
10 conditions on the list at that time. IRF officials have contended
that the list of conditions in the rule should be updated because of
changes in medicine that have occurred and the concomitant expansion of
the population that could benefit from inpatient rehabilitation
services.
The Conference Report that accompanied the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 directed us to issue a
report, in consultation with experts in the field of physical medicine
and rehabilitation, to assess whether the current list of conditions
represents a clinically appropriate standard for defining IRF services
and, if not, to determine which additional conditions should be added
to the list.[Footnote 8] In this testimony, I will discuss our April
2005 report, in which we (1) identified the conditions--on and off the
list--that IRF Medicare patients have and the number of IRFs that meet
the requirements of the 75 percent rule; (2) described how IRFs assess
patients for admission and whether CMS reviews admission decisions; and
(3) evaluated the approach of using a list of conditions in the 75
percent rule to classify IRFs.
In carrying out our work, we analyzed data from the Inpatient
Rehabilitation Facility--Patient Assessment Instrument (IRF-PAI)
records on all Medicare patients (the majority of patients in IRFs)
admitted to IRFs in fiscal year 2003[Footnote 9] (the most recent data
available at the time). The IRF-PAI records contain, for each Medicare
patient, the impairment group code[Footnote 10] identifying the
patient's primary condition and the diagnostic code from the
International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) identifying the patient's comorbid condition
(if any).[Footnote 11] We used these codes to determine whether we
considered the patient's primary or comorbid condition to be linked to
a condition on the list in the rule.[Footnote 12] We also spoke to 12
IRF medical directors, 10 fiscal intermediary officials, and contracted
with the Institute of Medicine (IOM) of the National Academies to
convene a 1-day meeting of 14 clinical experts in physical medicine and
rehabilitation to evaluate the approach of using a list of conditions
in the 75 percent rule. We conducted our work from May 2004 through
April 2005 in accordance with generally accepted government auditing
standards.
In brief, as noted in the report, in fiscal year 2003 fewer than half
of all IRF Medicare patients were admitted for having a primary
condition on the list in the 75 percent rule. Almost half of all
patients with conditions not on the list were admitted for orthopedic
conditions, and among those the largest group was joint replacement
patients. The experts IOM convened told us that uncomplicated
unilateral joint replacement patients rarely need to be admitted to an
IRF, and our analysis suggested that relatively few of the Medicare
unilateral joint replacement patients had comorbid conditions that
suggested a possible need for the IRF level of services. Additionally,
we found that only 6 percent of IRFs in fiscal year 2003 were able to
meet a 75 percent threshold. We also found that IRFs varied in the
criteria used to assess patients for admission, using patient
characteristics such as functional status, as well as condition. We
noted that CMS, working through its fiscal intermediaries, had not
routinely reviewed IRF admission decisions to determine whether they
were medically justified, although it reported that such reviews could
be used to target problem areas. The experts IOM convened and other
clinical and nonclinical experts we interviewed differed on whether
conditions should be added to the list in the 75 percent rule. The
experts IOM convened questioned the strength of the evidence for adding
conditions to the list--finding the evidence for certain orthopedic
conditions particularly weak--and some of them reported that little
information was available on the need for inpatient rehabilitation for
cardiac, transplant, pulmonary, or oncology patients. They called for
further research to identify the types of patients that need inpatient
rehabilitation and to understand the effectiveness of IRFs. There was
general agreement among all the groups of experts we interviewed that
condition alone is insufficient for identifying appropriate types of
patients for inpatient rehabilitation, since within any condition only
a subgroup of patients require the level of services of an IRF, and
that functional status should also be considered in addition to
condition.
We concluded that if condition alone is not sufficient for determining
which types of patients are most appropriate for IRFs, more conditions
should not be added to the list at the present time and the rule should
be refined to clarify which types of patients should be in IRFs as
opposed to another setting. As noted in the report, we recommended that
CMS ensure that targeted reviews for medical necessity are conducted
for IRF admissions; conduct additional activities to encourage research
on IRFs; and refine the 75 percent rule to more clearly describe the
subgroups of patients within a condition that are appropriate for IRFs,
possibly using functional status or other factors in addition to
condition. CMS generally agreed with our recommendations.
Background:
The 75 percent rule was established in 1983 to distinguish IRFs from
other facilities for payment purposes. According to CMS, the conditions
on the list in the rule at that time accounted for 75 percent of the
admissions to IRFs. In June 2002 CMS suspended the enforcement of the
75 percent rule after its study of the fiscal intermediaries revealed
that they were using inconsistent methods to determine whether an IRF
was in compliance and that in some cases IRFs were not being reviewed
for compliance at all. CMS standardized the verification process that
the fiscal intermediaries were to use, and issued a rule--effective
July 1, 2004--that increased the number of conditions from 10 to 13 and
provided a 3-year transition period, ending in July 2007, to phase in
the 75 percent threshold.[Footnote 13]
The current payment and review procedures for IRFs were established in
recent years. The inpatient rehabilitation facility prospective payment
system (IRF PPS) was implemented in January 2002. Payment is contingent
on an IRF's completing the IRF-PAI after admission and transmitting the
resulting data to CMS. Two basic requirements must be met if inpatient
hospital stays for rehabilitation services are to be covered: (1) the
services must be reasonable and necessary, and (2) it must be
reasonable and necessary to furnish the care on an inpatient hospital
basis, rather than in a less intensive facility, such as a SNF, or on
an outpatient basis.[Footnote 14] Determinations of whether hospital
stays for rehabilitation services are reasonable and necessary must be
based on an assessment of each beneficiary's individual care needs.
Beginning in April 2002, the fiscal intermediaries, the entities that
conduct compliance reviews, were specifically authorized to conduct
reviews for medical necessity to determine whether an individual
admission to an IRF was covered under Medicare.[Footnote 15]
Fewer Than Half of All IRF Medicare Patients in 2003 Were Admitted for
Conditions on List in Rule, and Few IRFs Were Able to Meet a 75 Percent
Threshold:
As we reported in April 2005, among the 506,662 Medicare patients
admitted to an IRF in fiscal year 2003, less than 44 percent were
admitted with a primary condition on the list in the 75 percent rule.
About another 18 percent of IRF Medicare patients were admitted with a
comorbid condition that was on the list in the rule. Among the 194,922
IRF Medicare patients that did not have a primary or comorbid condition
on the list in the rule, almost half were admitted for orthopedic
conditions, and among those the largest group was joint replacement
patients whose condition did not meet the list's specific criteria.
(See figure 1.)
Figure 1: Distribution of IRF Medicare Patients Who Did Not Have
Condition on List in Rule, by Condition as Defined by Impairment Group,
Fiscal Year 2003:
[See PDF for image] -graphic text:
Pie chart with 13 items and descriptive statistical table.
Conditions, as defined by impairment group: Joint replacements[A];
Number of patients who did not have primary or comorbid condition on
list in rule: 59,638;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 30.6.
Conditions, as defined by impairment group: Other orthopedic
conditions;
Number of patients who did not have primary or comorbid condition on
list in rule: 29,191;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 15.0.
Conditions, as defined by impairment group: Cardiac;
Number of patients who did not have primary or comorbid condition on
list in rule: 23,715;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 12.2.
Conditions, as defined by impairment group: Medically complex;
Number of patients who did not have primary or comorbid condition on
list in rule: 22,785;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 11.7.
Conditions, as defined by impairment group: Debility;
Number of patients who did not have primary or comorbid condition on
list in rule: 21,424;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 11.0.
Conditions, as defined by impairment group: Pain syndromes;
Number of patients who did not have primary or comorbid condition on
list in rule: 8,847;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 4.5.
Conditions, as defined by impairment group: Pulmonary disorders;
Number of patients who did not have primary or comorbid condition on
list in rule: 8,616;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 4.4.
Conditions, as defined by impairment group: Arthritis;
Number of patients who did not have primary or comorbid condition on
list in rule: 8,321;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 4.3.
Conditions, as defined by impairment group: Neurologic conditions;
Number of patients who did not have primary or comorbid condition on
list in rule: 6,576;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 3.4.
Conditions, as defined by impairment group: Other disabling
impairments;
Number of patients who did not have primary or comorbid condition on
list in rule: 4,145;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 2.1.
Conditions, as defined by impairment group: Brain dysfunction;
Number of patients who did not have primary or comorbid condition on
list in rule: 848;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 0.4.
Conditions, as defined by impairment group: Amputation;
Number of patients who did not have primary or comorbid condition on
list in rule: 796;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 0.4.
Conditions, as defined by impairment group: Developmental disability;
Number of patients who did not have primary or comorbid condition on
list in rule: 20;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 0.
Conditions, as defined by impairment group: Total;
Number of patients who did not have primary or comorbid condition on
list in rule: 194,922;
Percentage of total patients who did not have primary or comorbid
condition on list in rule: 100.0.
[A] Includes joint replacement patients who had a unilateral procedure
and those who were under age 85 and therefore did not meet two of the
three specific criteria for joint replacements set out in the 75
percent rule. (See app. I.) Codes from CMS for the third criterion--
body mass index--were not available.
[End of figure]
Although some joint replacement patients may need admission to an IRF,
such as those with comorbidities that affect the patient's function,
our analysis showed that few of these patients had comorbidities that
suggested a possible need for the level of services offered by an IRF.
Our analysis found that 87 percent of joint replacement patients
admitted to IRFs in fiscal year 2003 did not meet the criteria of the
rule, and among those, over 84 percent did not have any comorbidities
that would have affected the costs of their care based on our analysis
of the payment data.
Because the data we analyzed were from 2003, when enforcement of the
rule was suspended, we also looked at newly released data from July
through December 2004, after enforcement had resumed, to determine
whether admission patterns had changed. We focused on the largest
category of patients admitted to IRFs, joint replacement patients, and
found no material change in the admission of joint replacement patients
for the same time periods in 2003 and 2004. Across all IRFs, the
percentage of Medicare patients admitted for a joint replacement
declined by 0.1 percentage point.
In conjunction with our finding on the number of patients admitted to
IRFs for conditions not on the list in the rule, we determined that
only 6 percent of IRFs in fiscal year 2003 were able to meet a 75
percent threshold. Many IRFs were able to meet the lower thresholds
that would be in place early in the transition period, but
progressively fewer IRFs were able to meet the higher threshold levels.
IRFs Vary in the Criteria Used to Assess Patients for Admission, and
CMS Does Not Routinely Review IRFs' Admission Decisions:
As we stated in our report, the criteria IRFs used to assess patients
for admission varied by facility and included patient characteristics
in addition to condition. All the IRF officials we interviewed
evaluated a patient's function when assessing whether a patient needed
the level of services of an IRF. Whereas some IRF officials reported
that they used function to characterize patients who were appropriate
for admission (e.g., patients with a potential for functional
improvement), others said they used function to characterize patients
not appropriate for admission (e.g., patients whose functional level
was too high, indicating that they could go home, or too low,
indicating that they needed to be in a SNF). Almost half of the IRF
officials interviewed stated that function was the main factor that
should be considered in assessing the need for IRF services.
IRF officials reported to us that they did not admit all the patients
they assessed. Typically, the IRF received a request from a physician
in the acute care hospital requesting a medical consultation from an
IRF physician, or from a hospital discharge planner or social worker
indicating that they had a potential patient. An IRF staff member--
usually a physician and/or a nurse--conducted an assessment prior to
admission to determine whether to admit a patient.
CMS, working through its fiscal intermediaries, has not routinely
reviewed IRF admission decisions, although it reported that such
reviews could be used to target problem areas. Among the 10 fiscal
intermediary officials we interviewed, over half were not conducting
reviews of patients admitted to IRFs. We concluded that the presence of
patients in IRFs who may not need the intense level of services
provided by IRFs called for increased scrutiny of IRF admissions, which
could target problem areas and vulnerabilities and thereby reduce the
number of inappropriate admissions in the future. We recommended that
CMS ensure that its fiscal intermediaries routinely conduct targeted
reviews for medical necessity for IRF admissions. CMS agreed that
targeted reviews are necessary and said that it expected its
contractors to direct their resources toward areas of risk. It also
reported that it has expanded its efforts to provide greater oversight
of IRF admissions through local policies that have been implemented or
are being developed by the fiscal intermediaries.
Experts Differed on Adding Conditions to List in Rule but Agreed That
Condition Alone Does Not Provide Sufficient Criteria:
As we reported, the experts IOM convened and other experts we
interviewed differed on whether conditions should be added to the list
in the 75 percent rule but agreed that condition alone does not provide
sufficient criteria to identify types of patients appropriate for IRFs.
The experts IOM convened generally questioned the strength of the
evidence for adding conditions to the list in the rule. They reported
that the evidence on the benefits of IRF services is variable,
particularly for certain orthopedic conditions, and some of them
reported that little information was available on the need for
inpatient rehabilitation for cardiac, transplant, pulmonary, or
oncology conditions. In general, they reported that, except for a few
subpopulations, uncomplicated, unilateral joint replacement patients
rarely need to be admitted to an IRF. Most of them called for further
research to identify the types of patients that need inpatient
rehabilitation and to understand the effectiveness of IRFs in
comparison with other settings of care. IRF officials we interviewed
did not agree on whether conditions, including a broader category of
joint replacements, should be added to the list in the rule. Half of
them suggested that joint replacement be more broadly defined to
include more patients saying, for example, that the current
requirements were too restrictive and arbitrary. Others said that
unilateral joint replacement patients were not generally appropriate
for IRFs. We recommended that CMS conduct additional activities to
encourage research on the effectiveness of intensive inpatient
rehabilitation and factors that predict patient need for these
services. CMS agreed and said that it has expanded its activities to
guide future research efforts by encouraging government research
organizations, academic institutions, and the rehabilitation industry
to conduct both general and targeted research, and plans to collaborate
with the National Institutes of Health to determine how to best promote
research.
There was general agreement among all the groups of experts we
interviewed, including the experts IOM convened, that condition alone
is insufficient for identifying appropriate types of patients for
inpatient rehabilitation, because not all patients with a condition on
the list need to be in an IRF. For example, stroke is on the list, but
not all stroke patients need to go to an IRF after their
hospitalization. Similarly, cardiac condition is not on the list, but
some cardiac patients may need to be admitted to an IRF. Among the
experts convened by IOM, functional status was identified most
frequently as the information required in addition to condition. Half
of them commented on the need to add information about functional
status, such as functional need, functional decline, motor and
cognitive function, and functional disability. However, some of the
experts convened by IOM recognized the challenge of operationalizing a
measure of function, and some experts questioned the ability of the
current assessment tools to predict which types of patients will
improve if treated in an IRF.[Footnote 16]
We concluded that if condition alone is not sufficient for determining
which types of patients are most appropriate for IRFs, more conditions
should not be added to the list at the present time, and that future
efforts should refine the rule to increase its clarity about which
types of patients are most appropriate for IRFs. We recommended that
CMS use the information obtained from reviews for medical necessity,
research activities, and other sources to refine the rule to describe
more thoroughly the subgroups of patients within a condition that
require IRF services, possibly using functional status or other
factors, in addition to condition. CMS stated that while it expected to
follow our recommendation, it would need to give this action careful
consideration because it could result in a more restrictive policy than
the present regulations, and noted that future research could guide the
agency's description of subgroups.
Concluding Observations:
As we stated in our report, we believe that action to conduct reviews
for medical necessity and to produce more information about the
effectiveness of inpatient rehabilitation could support future efforts
to refine the rule over time to increase its clarity about which types
of patients are most appropriate for IRFs. These actions could help to
ensure that Medicare does not pay IRFs for patients who could be
treated in a less intensive setting and does not misclassify facilities
for payment.
Madam Chairman, this concludes my prepared statement. I would be happy
to respond to any questions you or other Members of the Subcommittee
may have at this time.
Contact and Staff Acknowledgments:
For further information about this testimony, please contact Marjorie
Kanof at (202) 512-7114. Linda Kohn and Roseanne Price also made key
contributions to this statement.
[End of section]
Appendix I: List of Conditions in CMS's 75 Percent Rule:
A facility may be classified as an IRF if it can show that, during a 12-
month period[Footnote 17] at least 75 percent of all its patients,
including its Medicare patients, required intensive rehabilitation
services for the treatment of one or more of the following
conditions:[Footnote 18]
1. Stroke.
2. Spinal cord injury.
3. Congenital deformity.
4. Amputation.
5. Major multiple trauma.
6. Fracture of femur (hip fracture).
7. Brain injury.
8. Neurological disorders (including multiple sclerosis, motor neuron
diseases, polyneuropathy, muscular dystrophy, and Parkinson's disease).
9. Burns.
10. Active, polyarticular rheumatoid arthritis, psoriatic arthritis,
and seronegative arthropathies resulting in significant functional
impairment of ambulation and other activities of daily living that have
not improved after an appropriate, aggressive, and sustained course of
outpatient therapy services or services in other less intensive
rehabilitation settings immediately preceding the inpatient
rehabilitation admission or that result from a systemic disease
activation immediately before admission, but have the potential to
improve with more intensive rehabilitation.
11. Systemic vasculidities with joint inflammation, resulting in
significant functional impairment of ambulation and other activities of
daily living that have not improved after an appropriate, aggressive,
and sustained course of outpatient therapy services or services in
other less intensive rehabilitation settings immediately preceding the
inpatient rehabilitation admission or that result from a systemic
disease activation immediately before admission, but have the potential
to improve with more intensive rehabilitation.
12. Severe or advanced osteoarthritis (osteoarthritis or degenerative
joint disease) involving two or more major weight bearing joints
(elbow, shoulders, hips, or knees, but not counting a joint with a
prosthesis) with joint deformity and substantial loss of range of
motion, atrophy of muscles surrounding the joint, significant
functional impairment of ambulation and other activities of daily
living that have not improved after the patient has participated in an
appropriate, aggressive, and sustained course of outpatient therapy
services or services in other less intensive rehabilitation settings
immediately preceding the inpatient rehabilitation admission but have
the potential to improve with more intensive rehabilitation. (A joint
replaced by a prosthesis no longer is considered to have
osteoarthritis, or other arthritis, even though this condition was the
reason for the joint replacement.)
13. Knee or hip joint replacement, or both, during an acute
hospitalization immediately preceding the inpatient rehabilitation stay
and also meet one or more of the following specific criteria:
a. The patient underwent bilateral knee or bilateral hip joint
replacement surgery during the acute hospital admission immediately
preceding the IRF admission.
b. The patient is extremely obese, with a body mass index of at least
50 at the time of admission to the IRF.
c. The patient is age 85 or older at the time of admission to the IRF.
FOOTNOTES
[1] See GAO, Medicare: More Specific Criteria Needed to Classify
Inpatient Rehabilitation Facilities, GAO-05-366 (Washington, D.C.: Apr.
22, 2005).
[2] IRFs are intended to serve patients recovering from medical
conditions that require an intensive level of rehabilitation. Not all
patients with a given condition may require the level of rehabilitation
provided in an IRF. For example, although a subset of patients who have
had a stroke may require the intensive level of care provided by an
IRF, others may be less severely disabled and require less intensive
services.
[3] In addition to IRFs, acute care hospitals, and SNFs, other settings
that provide rehabilitation services include long-term-care hospitals,
outpatient rehabilitation facilities, and home health care.
[4] See 42 U.S.C. §1395ww(d)(1)(B) (2000). The 75 percent rule was
initially issued in 1983 and most recently revised in 2004. See 42
C.F.R. §412.23(b)(2) (2004).
[5] For an annotated list of these conditions, see appendix I.
[6] Fiscal intermediaries are contractors to CMS that verify compliance
with the rule and conduct reviews for medical necessity to determine
whether an individual admission to an IRF is covered under Medicare.
[7] In addition to the 75 percent rule, an IRF must meet six regulatory
criteria showing that it had (1) a Medicare provider agreement; (2) a
preadmission screening procedure; (3) medical, nursing, and therapy
services; (4) a plan of treatment for each patient; (5) a coordinated
multidisciplinary team approach; and (6) a medical director of
rehabilitation with specified training or experience. IRFs must also
meet other criteria identified in 42 C.F.R. §412.22 (2004) and 42
C.F.R. §412.25 (2004).
[8] See H.R. Rep. 108-391, at 649 (2003).
[9] We analyzed the 2003 data using the 13 conditions in the current
regulation even though in fiscal year 2003 there were 10 conditions on
the list. Effective July 1, 2004, the number of conditions increased
from 10 to 13.
[10] The impairment group code identifies the medical condition that
caused the patient to be admitted to an IRF, and its sole function is
to determine payment rates. As a result, the impairment group codes
describe every patient in an IRF and include medical conditions that
are on the list in the rule as well as those that are not on the list
since IRFs may treat patients with conditions not on the list. In
contrast, the list of conditions in the rule describes the patient
population that is to be treated in an IRF to ensure that a facility is
appropriately classified to justify payment for the level of services
furnished.
[11] As used in this report, a primary condition is the first or
foremost medical condition for which the patient was admitted to an
IRF, and other medical conditions may coexist in the patient as
comorbid conditions, or comorbidities.
[12] Throughout this testimony, the "list in the rule" refers to the
list of 13 conditions as specified in the 2004 75 percent rule, and
when we say that condition is on (or off) the list, we mean that we
have (or have not) been able to link the condition as identified in the
patient assessment record to a condition on the list in the rule.
[13] During the transition period, the threshold increases each year
(from 50 percent to 60 percent to 65 percent) before the 75 percent
threshold is effective. The transition period also allows a patient to
be counted toward the required threshold if the patient is admitted for
either a primary or comorbid condition on the list in the rule. At the
end of the transition period, a patient cannot be counted toward the
required threshold on the basis of a comorbidity on the list in the
rule.
[14] Rehabilitative care in a hospital, rather than a SNF or on an
outpatient basis, is considered to be reasonable and necessary when a
patient requires a more coordinated, intensive program of multiple
services than is generally found outside of a hospital (Medicare
Benefit Policy Manual, chapter 1, Section 110.1).
[15] Prior to this time, Quality Improvement Organizations had this
authority. CMS Transmittal 21 made clear that fiscal intermediaries
have the authority to review admissions to IRFs.
[16] For example, one fiscal intermediary official reported that the
instrument that is currently used does not adequately measure progress
in small increments, such as a quadriplegic patient might experience.
Another respondent also reported that the current instrument only
measures functional status at a point in time, but does not predict
functional improvement.
[17] The time period is defined by CMS or the CMS contractor.
[18] See 42 C.F.R. §412.23(b)(2)(iii) (2004).
