The Effect of Medicare's Prospective Payment System on Patient Satisfaction

Identifying Homogeneous Outcome Groups in Adult Rehabilitation Using Cluster Analysis

IMPORTANCE

Adults receiving occupational therapy in inpatient rehabilitation are a heterogeneous population with differing needs, outcomes, and rehabilitation processes. Outcome studies based on what works for all clients may obscure the needs of population subgroups who benefit unequally from rehabilitation services.

OBJECTIVE

To identify subgroups on the basis of client satisfaction and progress in functional self-care among a diverse rehabilitation population and to understand subgroup differences in occupational therapy and rehabilitation processes and client discharge status.

DESIGN

Using an existing dataset, we used K-means cluster analysis of demographics, status at admission, and the outcomes of satisfaction and change in self-care to identify five homogeneous outcome groups. Occupational therapy and rehabilitation processes and discharge status were compared across subgroups.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

The dataset included 1,099 inpatients age 18 yr and older who received occupational therapy over a 27-mo period.

MEASURES

Admission measures included the Inpatient Rehabilitation Facility-Patient Assessment Instrument and self-care items of the FIM™. The Satisfaction with Continuum of Care-Revised was administered after discharge.

RESULTS

Five subgroups showed statistically different patterns of medical complications, functional self-care, rates of progress, satisfaction with intervention, and course of treatment. The profile of each group suggests differing therapeutic needs. Although all groups made significant gains in functional self-care, two groups continued to need physical assistance at discharge.

CONCLUSION

and Relevance: Cluster analysis proved useful in segmenting a typical heterogeneous rehabilitation population into more homogeneous subgroups to enhance understanding of clinical needs and to potentially increase the potency of outcomes research.

WHAT THIS ARTICLE ADDS

This research identified subgroups within a typical population of rehabilitation clients receiving occupational therapy and identified their unique needs and outcomes using cluster analysis techniques.

Factors predicting client satisfaction in occupational therapy and rehabilitation

Client satisfaction, a widely used outcome indicator of quality in health care, is inherently client centered and important in occupational therapy. We developed an instrument called the Satisfaction With Continuum of Care Revised (SCC-R) and tested a logistic regression model of satisfaction for six predictive research questions. Data collected from 769 clients from a large rehabilitation hospital using the SCC-R were paired with data that included demographics, functional status, and measures of the rehabilitation including occupational therapy. Satisfaction was stratified into two groups, satisfied and dissatisfied. The most robust and consistent predictors of satisfaction were functional status and improvements in functional status, presence of a neurological disorder, total rehabilitation hours, and admission to rehabilitation within 15 days of condition onset. The finding that improvements in functional status, especially self-care, were predictive of satisfaction is particularly relevant for occupational therapy. Implications for practice and future research are discussed.

Change in inpatient rehabilitation admissions for individuals with traumatic brain injury after implementation of the Medicare inpatient rehabilitation facility prospective payment system

OBJECTIVE

To evaluate the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on use of inpatient rehabilitation for individuals with traumatic brain injury (TBI).

DESIGN

Retrospective cohort study of patients with TBI.

SETTING

One hundred twenty-three level I and II trauma centers across the U.S. who contributed data to the National Trauma Data Bank.

PARTICIPANTS

Patients (N=135,842) with TBI and an Abbreviated Injury Score of the head of 2 or greater admitted to trauma centers between 1995 and 2004.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Discharge location: IRF, skilled nursing facility, home, and other hospitals.

RESULTS

Compared with inpatient rehabilitation admissions before IRF PPS came into effect, demographic characteristics of admitted patients changed. Those admitted to acute care trauma centers after PPS was enacted (January 2002) were older and nonwhite. No differences were found in rates of injury between men and women. Over time, there was a significant drop in the percent of patients being discharged to inpatient rehabilitation, which varied by region, but was found across all insurance types. In a logistic regression, after controlling for patient characteristics (age, sex, race), injury characteristics (cause, severity), insurance type, and facility, the odds of being discharged to an IRF after a TBI decreased 16% after Medicare's IRF PPS system was enacted.

CONCLUSIONS

The enactment of the Medicare PPS appears to be associated with a reduction in the chance that patients receive inpatient rehabilitation treatment after a TBI. The impact of these changes on the cost, quality of care, and patient outcome is unknown and should be addressed in future studies.

Performance of freestanding inpatient rehabilitation hospitals before and after the rehabilitation prospective payment system

BACKGROUND

Inpatient rehabilitation hospitals provide important services to patients to restore physical and cognitive functioning. Historically, these hospitals have been reimbursed by Medicare under a cost-based system; but in 2002, Medicare implemented a rehabilitation prospective payment system (PPS). Despite the implementation of a PPS for rehabilitation, there is limited published research that addresses the operating and financial performance of these hospitals.

PURPOSE

We examined operating and financial performance in the pre- and post-PPS periods for for-profit and nonprofit freestanding inpatient rehabilitation hospitals to test for pre- and post-PPS differences within the ownership groups.

METHODS

We identified freestanding inpatient rehabilitation hospitals from the Centers for Medicare and Medicaid Services Health Care Cost Report Information System database for the first two fiscal years under PPS. We excluded facilities that had fiscal years less than 270 days, facilities with missing data, and government facilities. We computed average values for performance variables for the facilities in the two consecutive fiscal years post-PPS. For the pre-PPS period, we collected data on these same facilities and, once facilities with missing data and fiscal years less than 270 days were excluded, computed average values for the two consecutive fiscal years pre-PPS. Our final sample of 140 inpatient rehabilitation facilities was composed of 44 nonprofit hospitals and 96 for-profit hospitals both pre- and post-PPS. We utilized a pairwise comparison test (t-test comparison) to measure the significance of differences on each performance variable between pre- and post-PPS periods within each ownership group.

FINDINGS

Findings show that both nonprofit and for-profit freestanding inpatient rehabilitation hospitals reduced length of stay, increased discharges, and increased profitability. Within the for-profit ownership group, the percentage of Medicare discharges increased and operating expense per adjusted discharge decreased.

PRACTICE IMPLICATIONS

Findings suggest that managers of these hospitals have adapted their administrative practices to conform with the financial incentives of the rehabilitation PPS. Managers must continue to control costs, increase discharges, and reduce length of stay to remain financially viable under the rehabilitation PPS.