What is Inpatient Rehabilitation?

Following acute-hospital care, many individuals with severe injuries or disabilities will be admitted to an inpatient rehabilitation hospital or unit.  In an inpatient rehab setting, individuals receive intensive, coordinated care by a team of health care professionals who specialize in the medical, physiological, and psychosocial aspects of rehabilitative health care.  Rehabilitation physicians and rehabilitation nurses must be available on a 24-hour basis and a physician must see the patient at least every two or three days.  Medicare requires that inpatient rehabilitation facilities provide individuals with intensive, multidisciplinary therapy as well as extensive medical management and the facility must have a medical director of rehabilitation with specified training/experience.

For most, the goal of inpatient rehabilitation is to help an individual regain his/her maximum level of independent function and return to independent, community living.  Unfortunately, government rules and regulations are making it more and more difficult for individuals in need of inpatient rehabilitative services to have appropriate access to this care.
 
What is the 75% Rule?

Currently, the Centers for Medicare and Medicaid Services (CMS) is phasing-in implementation of a rule (commonly referred to as the “75% Rule”) as a means of qualifying inpatient rehabilitation hospitals and units for reimbursement purposes. 

The rule states that facilities must maintain a particular percentage of patients receiving treatment for one or more of 13 conditions specified by CMS.  The thirteen conditions include typical types of rehabilitation cases such as stroke, spinal cord injury, amputation, brain injury, neurological disorders, and certain orthopedic conditions.  Of course, inpatient rehabilitation must be medically necessary for every patient who is treated in a rehabilitation hospital or unit, regardless of their condition.  The 75% Rule, however, gives preference to those with one of the 13 specified conditions.

In order to retain their qualification as an inpatient rehabilitation hospital or unit, these facilities are often forced to deny access to medically reasonable and necessary inpatient rehabilitation services to individuals who meet the strict admission criteria, but who do not happen to have one of the thirteen conditions on the list.  The impact of this restriction is essentially a quota system that leads to arbitrary judgments about who is admitted to intensive rehabilitation and who is diverted into nursing homes and lesser intense levels of care.

As a result, not only are individuals in need of intensive rehabilitative care being denied based on their diagnosis, but the stability of the entire inpatient rehabilitation system is being threatened as facilities are being forced to downsize or close their doors altogether when they cannot meet their 75% Rule quota.

As stated above, the 75% Rule is being phased-in.  The current threshold is 65%.  The rule is scheduled to be fully implemented on July 8, 2007 when the threshold will reach 75%.

Stopgap legislation has been introduced in both the Senate and House (S. 543/H.R. 1459) that would freeze implementation of 75% Rule and prevent additional access problem for individuals requiring inpatient rehabilitation care.  CPR Supports swift enactment of this legislation.

The House recently passed the Children’s Health and Medicare Protection (“CHAMP”) Act of 2007, which includes a freeze in the implementation of the 75% Rule at the 60% threshold indefinitely. The legislation would also allow patients’ comorbidities to continue to be considered for purposes of meeting the 75% Rule quota. CPR applauds the House passage of this legislation and encourages Senate action.

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