Rehabilitation Policy: Bracing for the Future

Thanks to the tenacious grassroots efforts of physiatrists and others, a major event took place late last year that has major implications for PM&R. The “75% Rule,” which loomed like a specter over the last few years and threatened to limit access to acute inpatient rehabilitation services (which would ultimately alter how physiatrists practice) was halted in a law signed by President Bush. The law held the rule at a 60% compliance threshold with the ability to count comorbidities. A recent issue of The Physiatrist newsletter summed it up well by calling the legislative act "groundbreaking." Indeed, freezing the rule at 60% completely alters the dynamic of its implementation, affecting not only admission numbers but also the fundamental and philosophical roles of inpatient rehabilitation facilities (IRFs). The freeze allows IRFs to acclimate more to the changing reimbursement environment of the Centers for Medicare & Medicaid Services (CMS), and also allows for continued analysis of the rule's impact on patient care and outcomes. The law also mandated that the secretary of Health and Human Services – in consultation with physicians, administrators of inpatient rehabilitation, acute care hospitals, skilled nursing facilities, government officials, and others – provide recommendations to Congress for classifying IRFs. (AAPM&R plans to be an active participant in the recommendations process.)

While many residents are aware of the new rule, it seems germane to point out the dual importance of this legislative change. First, it clearly conveys the power of organization and involvement. Medicine is rapidly metamorphosing into a field dominated by legal and business aspects, and it is up to physicians to stand up against these forces. If the necessity of action is inculcated in residents, then as professionals we may continue to ensure that the field remains focused on what is most important: patient care. But accomplishing this task requires education about health policy and the financial aspects of medicine. Only by understanding the larger, systems-based practice approach to health care can today’s residents maximize their potential.

Second, this shift in policy is important because of its larger implications for PM&R. The American Hospital Association (AHA) estimates that IRFs have already turned away large numbers of patients while facing staffing cuts, bed reductions, and service elimination. Thanks to the dedication of those in the field who have arduously fought against this legislation, such deleterious effects will be decelerated.

Clearly, there is still work to be done within PM&R to ensure that in the future, physicians – not legislators – dictate IRF admissions criteria and other important aspects of patient care. A major component of this effort lies in defining patients by functional ability and not purely by diagnosis. With strong organization and commitment, physiatrists can continue affecting positive changes at the legislative level well into the future. The challenge is to prepare residents to be involved in the process as well.

Douglas Elwood, MD, MBA
PGY3 – New York University

Jonathan Kirschner, MD
PGY3 – University of Medicine & Dentistry of New Jersey
 

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