Special feature: Rehab in 2010+

Continuum of care’ will be key words in 21st century

HCFA is hinting at a one-stop rehab shop

The government’s move in the past decade to change Medicare reimbursement for every segment of the health care continuum foreshadows what some industry experts say is a long-term plan to move to a system where Medicare makes one payment to one provider for all of a patient’s health care needs.

"What I think the government wants is a move towards total management," says Martin Schaeffer, MD, medical director of the department of physical medicine and rehabilitation at DuBois (PA) Regional Medical Center in DuBois, PA. Schaeffer predicts that the Health Care Financing Administration (HCFA) in Baltimore will use the data it collects from rehab facilities and other health care providers to determine what the total cost is to take care of any particular patient illness or catastrophe.

"I think they’re going to say, Based on historical data, we know what the total cost should be, and we’ll now pay one entity that total cost, and that entity can provide the ambulance, hospital, nursing home, rehab unit, and home health with that one lump payment,’" Schaeffer says.

This shift will force rehab facilities to form more contractual alliances, affiliations, and networks with other providers in order to create that seamless continuum of care from the moment a patient is injured or ill to the moment the patient is discharged from home health care, Schaeffer adds.

To survive, rehab facilities will need to be more flexible and less encumbered by physical or departmental walls, says J. Scott Gebhard, senior vice president for Solaris Health System and administrator of JFK Johnson Rehabilitation Institute in Edison, NJ. The health system has two acute care hospitals, three long-term care facilities with more than 600 beds, 100 comprehensive rehabilitation beds, and 20 outpatient settings. "Rehab facilities cannot lose focus on the skills needed to provide care, but they will need to provide it in different settings that may change from year to year," Gebhard says. "Within a very large health care system with acute hospitals, long-term care [LTC] facilities, outpatient, home care, etc., we’ll need rehab services that can effectively and efficiently work across those different environments," Gebhard adds.

Rehab facilities will have to cross-train staff and give therapists opportunities to work in different settings. For example, the Solaris Health System has a team of 80 physical therapists who rotate and cross-train for work across the entire continuum of care, Gebhard says.

Rotation provides learning opportunity

"We have permanent positions in LTC, but we’ll rotate the permanent positions, and this gives the therapist an incredible learning opportunity," he explains. "It affords the health system the ability to have some flexibility in its staffing, and it’s been set up so it’s not done as an onerous burden, but to give therapists options and to award them the ability to move from environment to environment without having to leave our system."

At Solaris Health System, staff physicians also cover the entire continuum of care, including acute care, inpatient, and subacute care, Gebhard says. "It’ll be the same team, but not necessarily the same physician," he notes. "We have 20 full-time physiatrists with a common medical leader."

Large health systems, such as Solaris, may find it easier to own their entire continuum of care. Most other systems will probably have to struggle with the pros and cons of ownership, says Kurt Hoppe, MD, medical director of rehabilitation and post-acute care services of the Iowa Health System in Des Moines. The health system’s rehab unit has 54 inpatient beds and provides outpatient services.

"The question all health systems have to wrestle with is how much of the continuum do you own, and how much do you outsource?" Hoppe says. "It used to be easier to manage those [rehab] patients, but nowadays, given the fact of inadequate reimbursement, especially in skilled nursing, it’s hampered our ability to move those people as efficiently as possible along the continuum."

Health systems that increase their flexibility to move rehab patients through a continuum of care, whether it’s through ownership or partnerships, still will have to contend with HCFA’s regulations that are intended to thwart providers from moving patients to less expensive levels of care without consideration of clinical outcomes.

HCFA will watch for gaming’

"We do know that HCFA sees that scenario as a potential for gaming the system and has tried to build into each different step in the PPS [prospective payment system] process measures to prevent people from being inappropriately transferred," says Sheldon Herring, PhD, clinical director of the traumatic brain injury program at Roger C. Peace Rehabilitation Hospital in Greenville, SC. HCFA will have penalties for providers who discharge patients too quickly to inappropriate levels along the continuum of care, Herring adds.

Nonetheless, it’s clear that HCFA would love to see all acute care, rehab, home health, and other types of medical care bundled under one super-payment, Herring says. This is not necessarily a bad thing, but for it to succeed there will need to be certain conditions, he maintains. Herring outlines these conditions for success:

• The amount of reimbursement must be reasonable.
• The purchaser, whether it’s the U.S. government or an insurance company, should give the provider some significant clinical latitude along with the financial burden.
• The purchaser should purchase a level of outcome and not try to prescribe the process or different options to be considered.

"Where it becomes a losing situation for the provider is when we absorb the entire financial risk, and then the payer comes in and says we don’t want any of that money spent for adult day care or for transportation," Herring says. "I think in the beginning, HCFA’s checks and balances might end up being intrusive."