Did the Medicare Inpatient Rehabilitation Facility Prospective Payment System Result in Changes in Relative Patient Severity and Relative Resource Use?

Background Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals. Conclusions The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.

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Abstract TMP47: Impact of Medicare Reform on Inpatient Rehabilitation Facility Access for Hemorrhagic Stroke Patients

Stroke ◽

10.1161/str.51.suppl_1.tmp47 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Nneka L Ifejika ◽

Farhaan Vahidy ◽

Mathew Reeves ◽

Xian Ying ◽

Roland Matsouaka ◽

...

Keyword(s):

Skilled Nursing Facility ◽

Inpatient Rehabilitation ◽

Prospective Payment System ◽

Sensitivity Analyses ◽

Teaching Hospitals ◽

Admission Criteria ◽

Stroke Patients ◽

Rehabilitation Facility ◽

Inpatient Rehabilitation Facility ◽

The Impact

Introduction: There is growing evidence that ICH patients make larger & faster recovery gains compared to ischemic stroke patients. Inpatient rehabilitation facility (IRF) care can significantly facilitate improvement. In 2010, changes to IRF admission criteria potentially restricted access. We hypothesize the Centers for Medicare and Medicaid Services (CMS) 2010 IRF Prospective Payment System Rule decreased IRF access & increased skilled nursing facility (SNF) utilization in ICH patients. Methods: The proportion of ICH survivors discharged to IRF, SNF or home was estimated using GWTG-Stroke data between 1/1/2008 & 12/31/2015 (n=265,444). Two binary hierarchical models determined the association between the 1/1/2010 CMS admission criteria change for IRFs and discharge setting, adjusting for patient & hospital characteristics. Subgroup analyses evaluated the effects of age, region & hospital type. Sensitivity analyses used complete NIHSS data (≈49%). Results: The prevalence of the 3 discharge destinations changed significantly over time (CMH row-mean-score P<0.0001; Figure 1). IRF rehab odds decreased and SNF rehab odds increased for ICH patients compared to home after the CMS 2010 IRF PPS Rule (Figure 2a & 2b). Decreased IRF rehab odds were found in patients age<65, Western US location or at non-teaching hospitals (Figure 2a). Increased SNF rehab odds were found in patients age≥65, Midwest location or at teaching hospitals (Figure 2b). Conclusions: IRF Rehab odds decreased and SNF rehab odds increased during the time period after CMS 2010 IRF PPS Rule implementation in ICH patients. The impact of such legislative changes on patient outcomes warrants further study.

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