Impact of a function-based payment model on the financial performance of acute inpatient medical rehabilitation providers: a simulation analysis

The Early Impact of the Inpatient Rehabilitation Facility Prospective Payment System on Stroke Rehabilitation Case Mix, Practice Patterns, and Outcomes

DeJong G, Horn SD, Smout RJ, Ryser DK. The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes.

OBJECTIVE

To determine the early effects of the inpatient rehabilitation facility (IRF) prospective payment system (PPS) on stroke rehabilitation case mix, practice patterns, and outcomes.

DESIGN

Prospective observational cohort study.

SETTING

Three IRFs in the United States.

PARTICIPANTS

Consecutively enrolled convenience sample of 539 stroke rehabilitation patients treated between 2001 and 2003 in 3 IRFs.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Length of stay (LOS), therapy utilization, FIM instrument gain, and discharge destination.

RESULTS

The IRF-PPS had no material short-term effect on stroke rehabilitation case mix and LOS for the study facilities. Facilities shifted physical and occupational therapy resources from those in the most severe case-mix groups (CMGs) to those in the moderate CMGs. Those in the more severe CMGs also experienced a noticeable decline in FIM score gain over the course of the rehabilitation stay. Using multivariate analyses, the authors discerned no major role for the IRF-PPS in explaining pre- and post-PPS differences in utilization and outcome among study facilities.

CONCLUSIONS

For the 3 study facilities, IRF-PPS did not materially reshape stroke rehabilitation case mix, utilization, and outcome in the early stages of PPS implementation, apart from the shift in therapy resources from more severely involved stroke patients to moderately involved patients. The study's findings are limited to 3 facilities, and a longer time horizon is needed to more fully determine the effects of the IRF-PPS.

Evaluating diagnosis-based risk-adjustment methods in a population with spinal cord dysfunction

OBJECTIVE

To examine performance of models in predicting health care utilization for individuals with spinal cord dysfunction.

DESIGN

Regression models compared 2 diagnosis-based risk-adjustment methods, the adjusted clinical groups (ACGs) and diagnostic cost groups (DCGs). To improve prediction, we added to our model: (1) spinal cord dysfunction-specific diagnostic information, (2) limitations in self-care function, and (3) both 1 and 2.

SETTING

Models were replicated in 3 populations.

PARTICIPANTS

Samples from 3 populations: (1) 40% of veterans using Veterans Health Administration services in fiscal year 1997 (FY97) (N=1,046,803), (2) veteran sample with spinal cord dysfunction identified by codes from the International Statistical Classification of Diseases, 9th Revision, Clinical Modifications (N=7666), and (3) veteran sample identified in Veterans Affairs Spinal Cord Dysfunction Registry (N=5888).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Inpatient, outpatient, and total days of care in FY97.

RESULTS

The DCG models (R(2) range,.22-.38) performed better than ACG models (R(2) range,.04-.34) for all outcomes. Spinal cord dysfunction-specific diagnostic information improved prediction more in the ACG model than in the DCG model (R(2) range for ACG,.14-.34; R(2) range for DCG,.24-.38). Information on self-care function slightly improved performance (R(2) range increased from 0 to.04).

CONCLUSIONS

The DCG risk-adjustment models predicted health care utilization better than ACG models. ACG model prediction was improved by adding information.

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system

BACKGROUND

Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system.

OBJECTIVE

The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences.

DESIGN

This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system.

SUBJECTS

The study included 55,438 stroke patients.

MEASURES

Study measures were LOS, functional status at discharge, and community discharge.

RESULTS

The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05).

CONCLUSIONS

While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.