Impact of Medicare Prospective Payment System on Acute Rehabilitation Outcomes of Patients With Spinal Cord Injury

doi:10.1016/j.apmr.2010.07.236

Archives of Physical Medicine and Rehabilitation

Volume 92, Issue 3, March 2011, Pages 346-351

https://doi.org/10.1016/j.apmr.2010.07.236 Get rights and content

Abstract

Qu H, Shewchuk RM, Chen Y, Deutsch A. Impact of Medicare prospective payment system on acute rehabilitation outcomes of patients with spinal cord injury.

Objective

To examine the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on inpatient rehabilitation outcomes for patients with traumatic spinal cord injury (SCI).

Design

Retrospective study.

Setting

Twelve SCI Model Systems.

Participants

A sample of Medicare (n=296) and non-Medicare (n=3110) patients was selected from the National SCI Statistical Center Database from 1996 to 2006.

Interventions

Not applicable.

Main Outcome Measures

Motor FIM score change and length of stay (LOS).

Results

LOS decreased by about 5.8 days a year (P<.001) for Medicare patients and about 1.3 days a year (P=.031) for non-Medicare patients after PPS implementation. However, for both groups, FIM score gains were not significantly different in the pre-PPS and PPS periods.

Conclusions

Although significant decreases in LOS were observed for Medicare patients after IRF PPS implementation, Medicare patients' improvements in motor function did not decrease. Non-Medicare patients with SCI also experienced shortened stays after Medicare IRF PPS implementation, but had equivalent FIM score gains compared with their counterparts who received inpatient rehabilitation care before PPS implementation. IRF PPS implementation was associated with shorter stays, but was not associated with lower functional improvement.

Section snippets

Participants

The data used in this study were retrieved from the NSCID, which has existed since 1973 and is believed to capture data from about 13% of new SCI cases every year in the United States. The NSCID contains data from 26 federally funded SCIMSs, including demographic and medical variables, functional status, and psychosocial outcomes, during the initial hospital care and follow-up data at 1, 5, and then every 5 years postinjury.12, 13

The present study includes patients who received acute inpatient

Results

Of 3406 eligible patients, 296 (8.7%) had Medicare as a primary payer. Table 1 lists characteristics of Medicare and non-Medicare patients by PPS status. There were no significant differences in age, sex, race, highest education level achieved, marital status, and admission FIM motor scores before/after PPS implementation between Medicare and non-Medicare patients. A slightly higher percentage of complete paraplegia and lower percentage of incomplete paraplegia before PPS (vs PPS) were observed

Discussion

The IRF PPS was introduced by the Centers for Medicare & Medicaid Services as a strategy to decrease health care costs by improving the efficiency of rehabilitation care for Medicare beneficiaries in an inpatient setting. The intent of the IRF PPS is to encourage IRFs to allocate and use resources more efficiently.2, 3 To keep facility costs at less than Medicare payments, facilities may decrease individual patient costs by decreasing LOSs, a practice documented by previous studies.21, 22, 23,

Conclusions

Although Medicare patients with SCI who received inpatient rehabilitation care after PPS implementation had significantly shorter stays than those who received rehabilitation care before PPS implementation, motor FIM score gains for Medicare patients with SCI did not decrease with the shortened LOS. Non-Medicare patients with SCI also experienced shortened stays after Medicare IRF PPS implementation, but had equivalent FIM score gains compared with their counterparts who received inpatient

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Citation Excerpt :
The FIM instrument was developed to assess a person's level of disability in terms of burden of care.23 Using FIM data, we created the outcome measure change in mFIM, which includes 12 items covering self-care, sphincter control, transfers, and locomotion dimensions.24,25 In this study, the tub/shower transfer item was excluded from transfers because scores have been shown to vary based on the environment (use of roll-in shower or tub) and thus may not always reflect a person's level of disability.26
To examine the modifying effect of body mass index (BMI) on the association between rehabilitation length of stay (LOS), severity of injury, and motor FIM (mFIM) improvement in patients with traumatic spinal cord injury (TSCI).
Retrospective cohort study.
Seventeen SCI Model Systems (SCIMS) centers in the United States.
A total of 3413 patients (N=3413) who had a TSCI were admitted to an SCIMS between October 2011 and August 2018.
Not applicable.
The mFIM (12 items) improvement by discharge. Four rehabilitation LOS groups split by quartiles were created for each neurologic severity of injury group (C1-C4 level with American Spinal Injury Association Impairment Scale [AIS] ABC, C5-C8 AIS ABC, T1-S3 AIS ABC, AIS DE). The interrelationship among rehabilitation LOS, BMI, and mFIM improvement were examined using multivariate linear regressions. A stratified analysis was performed to examine the association between rehabilitation LOS and mFIM improvement by BMI status (underweight or normal weight, overweight, obesity) and neurologic groups.
A total of 1099 (32.2%) and 821 (24.1%) patients were overweight and had obesity, respectively. Patients with obesity had less improvement in mFIM than those who were underweight or normal weight (unit of mFIM improvement, −3.71). After stratifying by BMI status, among patients with obesity, those with the longest rehabilitation LOS showed greater improvement in mFIM than those in the shortest LOS (unit of mFIM improvement=4.78).
Longer inpatient rehabilitation LOS may benefit patients with TSCI by increasing mFIM improvement by discharge. Obesity is negatively associated with mFIM improvement.
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Secondary data analysis.
U.S. Medicare-certified IRFs (N=983).
Data included patient records of Medicare beneficiaries (N=34,364) admitted in 2009 for rehabilitation after hip fracture.
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Performance-based outcomes included mean motor function on discharge, mean motor change (mean motor score on discharge minus mean motor score on admission), and percentage discharged to the community.
Higher mean motor function on discharge was explained by aggregate characteristics of patients with hip fracture (lower age [P=.009], lower percentage of blacks [P<.001] and Hispanics [P<.001], higher percentage of women [P=.030], higher motor function on admission [P<.001], longer length of stay [P<.001]) and facility characteristics (freestanding [P<.001], rural [P<.001], for profit [P=.048], smaller IRFs [P=.014]). The findings were similar for motor change, but motor change was also associated with lower mean cognitive function on admission (P=.008). Higher percentage discharged to the community was associated with aggregate patient characteristics (lower age [P<.001], lower percentage of Hispanics [P=.009], higher percentage of patients living with others [P<.001], higher motor function on admission [P<.001]). No facility characteristics were associated with the percentage discharged to the community.
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This article serves as an introduction to this issue of the Archives of Physical Medicine and Rehabilitation that is devoted to current research findings of the Spinal Cord Injury Model Systems (SCIMS) program. The SCIMS program began in 1970, with funding from the National Institute on Disability and Rehabilitation Research in the U.S. Department of Education, to demonstrate a comprehensive care system for spinal cord injury (SCI) and also to conduct research to improve the health and quality of life of persons with SCI. Over the last 20 years, similar collaborative efforts for the dissemination of SCIMS research outcomes have produced conference proceedings in 1990, a book in 1995, and dedicated journal issues in 1999 and 2004. The collection of 24 articles in this issue shows the depth and breadth of work being carried out by the SCIMS investigators, from descriptive epidemiology to a randomized controlled trial, from neurologic recovery to community reintegration, and from health services utilization to assistive technology for mobility. Herein, we provide a brief overview of the SCIMS program, highlight the research initiatives currently underway, and describe the important findings of the original research articles contained in this issue.
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Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care
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: Supported by the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitation Services, U.S. Department of Education, Washington, DC (grant nos. H133A060039 and H133N060014).

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

: Reprints are not available from the author.

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Original articleImpact of Medicare Prospective Payment System on Acute Rehabilitation Outcomes of Patients With Spinal Cord Injury

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Results

Discussion

Conclusions

Arch Phys Med Rehabil

J Health Econ

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

IRF perspective payment system: an update

Rehab Manag

A case-mix classification system for medical rehabilitation

Med Care

The impact of the inpatient rehabilitation facility prospective payment system on stroke program outcomes

Arch Phys Med Rehabil

Impact of Medicare's prospective payment system for inpatient rehabilitation facilities on stroke patient outcomes

Am J Phys Med Rehabil

A study of stroke post-acute care costs and outcomes: final reportExecutive summary

Original article
Impact of Medicare Prospective Payment System on Acute Rehabilitation Outcomes of Patients With Spinal Cord Injury