Home Health & Hospice Week

CMS charges ahead with major change for joint replacement patients' site of service.

A major shake-up for inpatient rehabilitation facilities could translate to major referrals for your therapy services.

The Centers for Medicare & Medicaid Services is moving full steam ahead with the so-called 75 percent rule for IRFs. Under the rule, rehab hospitals must show that at least three-quarters of their inpatient population over the most recent 12-month cost reporting period required "intensive rehabilitation services for 10 serious medical conditions," such as stroke, amputations and brain injuries.

A phase-in period will soften the blow. Starting this month, 60 percent of admissions must meet one of the qualifying diagnoses; the ratio raises to 65 percent on July 1, 2006, and leaps to 75 percent on July 1, 2007.

Those stringent requirements, even as they're being phased in, will require IRFs to turn down many therapy patients that could end up on home health agencies' rolls, experts say.

CMS suspended the rule's enforcement in January, pending a study by the Government Accountability Office of clinically appropriate IRF classification criteria. The GAO released that study in April, but CMS says it already has been taking the steps the GAO recommended. CMS will begin enforcing the classification criteria outlined in the final rule, the agency says in a notice published June 24 in the Federal Register.

Close on the heels of the GAO's April report on the 75 percent rule came the Medicare Payment Advisory Commission's analysis of the rule's impact on joint replacement patients (see Eli's HCW, Vol. XIV, No. 16). Under the rule's classification criteria, many knee or hip replacement patients no longer will receive therapy from an IRF.

Instead, these patients will have longer acute hospital stays or will be discharged to other settings, such as home health agencies, skilled nursing facilities and outpatient facilities, MedPAC predicts in its June report to Congress.

A panel of orthopedic surgeons told MedPAC "patients who have had a hip or knee replaced ideally should go home with either home health care or outpatient therapy services." Between 50 percent and 85 percent of their Medicare patients go home from the hospital in two to four days following surgery, the report says.

Some IRFs already have stopped accepting joint replacement cases in light of the 75 percent rule, MedPAC reports. That means HHAs, SNFs and outpatient providers are in a position to receive more of these patients than ever before - and that opportunity will increase as the compliance threshold increases to the full 75 percent.

Seize the Marketing Moment

The IRF change is positive for home care providers and patients, notes Cindy Krafft, director of rehab services for OSF Home Care in Peoria, IL. "Many orthopedic patients really don't need to be in a facility," she tells Eli.

Now is the time for HHAs to seize the opportunity and stress their therapy services to referral sources, Krafft suggests. The industry "hasn't done the best job in promoting the rehab available to patients in home health," she notes. "A lot of physicians, referral sources and the public see home health as nursing."

If agencies fail to communicate their therapy resources to referral sources, patients who formerly went to IRFs are likely to end up in SNFs instead of home care, she warns.

Potential problem area: Knee and hip replacement patients who formerly went to an IRF might initially require daily visits from an HHA, Krafft notes. Providing this kind of intensive therapy could make the agency appear to be boosting therapy visits to make the 10-visit therapy threshold that allows for an additional $2,000 per episode in reimbursement, she warns.

To protect themselves, HHAs will need bulletproof documentation showing that the patient really needs that much therapy, Krafft says.

Note: MedPAC's reports are at www.medpac.gov. CMS' June 24 Federal Register notice is at www.access.gpo.gov/su_docs/fedreg/a050624c.html.