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Functional gains, treatment hours drop
A study by a NovaCare subsidiary offers support to a concern many rehab managers are voicing in light of life under a prospective payment system (PPS) environment: Functional gains do indeed decline, but not in direct proportion to reductions in the number of treatment hours.
Data from the study, which reviewed functional gains and length of treatment for more than 100,000 skilled nursing facility (SNF) rehabilitation patients, show that while there is room for productivity improvements in SNFs, reimbursement cuts implemented under PPS may have gone too far.
The bad news: Functional Independence Measurement (FIM) scores declined 15% for the more than 1,000 NovaCare patients studied between July 1998 and April 1999, says Reg L. Warren, PhD, vice president of outcomes research for The Polaris Group Inc., a subsidiary of NovaCare in King of Prussia, PA. Many rehab facilities used FIM scores as a way to measure the influence of therapy on patient activities of daily living skills such as dressing, toileting, and eating.
The good news: That’s not quite as drastic compared to the 42% decline in the number of treatment hours delivered to those patients (34 average hours of patient care under PPS, compared with 58 hours previously). Clearly, the disparity shows there’s room for greater efficiency in the rehabilitation process, Warren says.
Early indications are that an optimal threshold of care can be reached through a correct balance between reimbursement and utilization of therapy that is about halfway between current payment rates and the way SNFs were paid previously, Warren concludes.
An analysis of 1,311 patients under the PPS system and 208 patients under the cost-based system found that while the average patient age (82) and initial disability based on FIM measurements (61) were identical, functional outcomes following treatment declined from a 20-point gain in FIM scores to a 17-point gain in FIM scores. (See chart, p. 92.)
"That roughly correlates with an increase in the burden of care for these patients of nine to 10 minutes per day," Warren says. " If that care happens to be, for instance, in toilet transfers or communicating in an emergency situation, that can be a very predictive of whether a given patient can return to the community. (However, current levels of discharge to the community have not declined significantly.) The chart on p. 92 also reveals the following information:
1. The average number of days between a patient’s initial admission to the hospital and his or her admission to a skilled nursing facility increased from 15 days to 17 days. That likely is due to the implementation of a transfer rule by the Health Care Financing Administration, Warren says. The transfer rule gives hospitals incentives to keep patients in certain diagnostic groups for a longer portion of their diagnostic group’s length of stay.
2. Length of stay at NovaCare facilities was roughly the same — 28 days under PPS, compared with 27 days previously. Warren says he expects a trend in which providers will lengthen rehab lengths of stay in compensation for less treatment per day. However, it is unknown whether more treatment will offset the loss of intensity of the treatment.
Further data analyses of NovaCare patients found the following:
1. Utilization of various severity levels of patients varied greatly. Patients with either very low FIM scores (indicating they were severely disabled with little hope of significant improvement) and very high FIM scores (indicating disabilities were minimal) received less care than patients in the middle of the spectrum, who exhibited a fairly high level of disability but showed good potential for improvement.
2. Overall, patients received an average of 571 minutes of care a week, although patients with low FIM scores received 475 minutes of care per week while patients with high FIM scores received an average of 500 minutes of care per week. This inverse, U-shaped curve is somewhat parallel with trends under the cost-based system but at a lower overall utilization level, Warren says. That is, regardless of payment incentive, clinicians tend to administer treatment intensity in terms of their perception of patient need, which is influenced by their perception of patient disability (e.g., admission FIM score).
3. An optimal level of care for orthopedic patients studied was 60 hours. After that point, functional improvements leveled off. Unfortunately, reimbursement under PPS for these patients only totaled an average 38 hours. "That’s why FIM gains dropped 25% for the orthopedics group," Warren points out. "Unfortunately, PPS is a per-diem rather than episodic payment system. This results in an almost microscopic focus on daily utilization and not upon case management of the post-acute care episode as a whole. As utilization levels are managed closer to the RUGs’ [Resource Utilization Groups] caps, further decline in outcomes can be expected."
Initially, under a prospective pay system, therapists and other providers tend to deliver more care than they are reimbursed for. A utilization and admission FIM analysis of 1,311 PPS patients found that an average of 571 minutes of care a week was delivered, compared with the allowable reimbursement under RUGs, the PPS reimbursement system for SNFs, of 485 minutes of patient care. (See chart, p. 93.)
Those trends are similar to what rehabilitation providers experience as managed care markets emerge, Warren explains. Typically, if a facility increases the number of capitated contracts it has, therapists and other clinicians will not automatically reduce the amount of care they give to patients for fear of short-changing them.
"There’s understandable resistance early on," he explains. "The key to getting buy-in from the clinical side of the process is to establish a baseline concerning outcomes [such as functional gains under cost-based standards], and then work together to change system inefficiencies and the clinical process itself to allow the same results with less utilization."
However, for each diagnostic group, there is a threshold at which further reduction of utilization has a negative effect on clinical results, no matter what you do. Prospective pay is no different, he says. "The way to find the optimal level of care is to experiment with utilization allowances defined by the payment system or contract using techniques like case management, data-based decision support, and support personnel."
Warren says the Polaris/NovaCare data provide a glimpse of what may occur in the prospec tive pay system for rehab hospitals. "But hospitals will probably be able to adapt more quickly because they already have better infrastructure in place, such as case managers." He says the response of hospitals also will be influenced by the impact of PPS on utilization relative to allowances under the Tax Equity and Fiscal Responsibility Act; if they are anywhere near the 40% reduction experienced by the SNF industry, quality is likely to suffer regardless of adjustments made.
Speaking of putting data to work, what does NovaCare plan to do with the results of its study? Warren says the SNF industry is using this type of data to make the regulatory community aware of the impact of current laws on SNF rehabilitation and the quality of patients’ lives. n