Medicare Compliance & Reimbursement

Longer stays are already a reality after joint replacement shakeup.

Rehab managers in acute care have their work cut out for them: How to contend with a harsh new reality without draining hospital resources.

"The 75 percent rule promises a backlash that many acute rehab providers are feeling already," reports Fran Fowler of Fowler Healthcare Associates in Atlanta. Offering only a few exceptions in the rule, the Centers for Medicare and Medicaid Services has made it clear that beneficiaries who undergo hip or knee replacement surgery now should receive rehab services in a setting other than an inpatient rehabilitation facility. Many IRFs, faced with federal audits and the threat of decertification, have stopped accepting joint replacement referrals, confirms Jason Levine of Joliet, IL's Murer Consultants, adding that facilities began doing so well before CMS' June announcement that it would proceed with enforcing the 75 percent rule.

"Starting now, most of those patients must get services somewhere else," summarizes Fowler. The solution in some cases has been for acute care providers to extend patients' lengths of stays, offering more intensive therapy than they might have in the past.

While experts initially expected that most joint patients would be discharged to skilled nursing facilities or home care for therapy, variables in staffing and training make it difficult to predict which alternate providers are up to the task, says Fowler.

Translation: Hospitals are forced to do more for patients with no increase in pay, at a time when most already are facing deficits when it comes to covering the cost of care provided Medicare beneficiaries.

Statistically, the shift in where patients receive rehabilitation services following lower extremity joint replacement surgery could be huge.

In 2003, hospitals discharged 428,518 patients following unilateral joint replacement surgery (hips or knees). Approximately 125,000 patients were sent to IRFs for rehab, reports the Government Accountability Office. Another 14,420 patients underwent bilateral procedures (i.e., double hip or knee replacements), with nearly half (6,941) being discharged to IRFs.