Fewer Than Half of All IRF Medicare Patients in 2003 Were Admitted for Conditions on List in Rule, and Few IRFs Were Able to Meet a 75 Percent Threshold

As we reported in April 2005, among the 506,662 Medicare patients  admitted to an IRF in fiscal year 2003, less than 44 percent were admitted  with a primary condition on the list in the 75 percent rule. Among the 194,922 IRF Medicare  patients that did not have a primary or comorbid condition on the list in  the rule, almost half were admitted for orthopedic conditions, and among  those the largest group was joint replacement patients whose condition  did not meet the list’s specific criteria. Although some joint replacement patients may need admission to an IRF,  such as those with comorbidities that affect the patient’s function, our  analysis showed that few of these patients had comorbidities that  suggested a possible need for the level of services offered by an IRF. In conjunction with our finding on the number of patients admitted to  IRFs for conditions not on the list in the rule, we determined that only   6 percent of IRFs in fiscal year 2003 were able to meet a 75 percent  threshold. CMS, working through its fiscal intermediaries, has not routinely reviewed  IRF admission decisions, although it reported that such reviews could be  used to target problem areas. Experts Differed on Adding Conditions to List in Rule but Agreed That Condition Alone Does Not Provide Sufficient Criteria

As we reported, the experts IOM convened and other experts we  interviewed differed on whether conditions should be added to the list in  the 75 percent rule but agreed that condition alone does not provide  sufficient criteria to identify types of patients appropriate for IRFs. The experts IOM convened generally questioned the strength of the  evidence for adding conditions to the list in the rule. They reported that  the evidence on the benefits of IRF services is variable, particularly for  certain orthopedic conditions, and some of them reported that little  information was available on the need for inpatient rehabilitation for  cardiac, transplant, pulmonary, or oncology conditions. In general, they  reported that, except for a few subpopulations, uncomplicated, unilateral  joint replacement patients rarely need to be admitted to an IRF. Most of  them called for further research to identify the types of patients that need  inpatient rehabilitation and to understand the effectiveness of IRFs in  comparison with other settings of care. There was general agreement among all the groups of experts we  interviewed, including the experts IOM convened, that condition alone is  insufficient for identifying appropriate types of patients for inpatient  rehabilitation, because not all patients with a condition on the list need to  be in an IRF. Among the experts convened by IOM, functional status was identified  most frequently as the information required in addition to condition. We concluded that if condition alone is not sufficient for determining  which types of patients are most appropriate for IRFs, more conditions  should not be added to the list at the present time, and that future efforts  should refine the rule to increase its clarity about which types of patients  are most appropriate for IRFs. Appendix I: List of Conditions in CMS’s 75 Percent Rule

A facility may be classified as an IRF if it can show that, during a 12-month  period at least 75 percent of all its patients, including its Medicare  patients, required intensive rehabilitation services for the treatment of one  or more of the following conditions:1.
Why GAO Did This Study

Medicare classifies inpatient rehabilitation facilities (IRF) using the "75 percent rule." If a facility can show that during a 12-month period at least 75 percent of its patients required intensive rehabilitation for 1 of 13 listed conditions, it may be classified as an IRF and paid at a higher rate than for less intensive rehabilitation in other settings. Because this difference can be substantial, it is important to classify IRFs correctly. GAO was asked to discuss issues relating to the classification of IRFs, and in April 2005 it issued a report, Medicare: More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities (GAO-05-366). For that report, GAO analyzed data on all Medicare patients (the majority of patients in IRFs) admitted to IRFs in fiscal year 2003, spoke to IRF medical directors, and had the Institute of Medicine (IOM) convene a meeting of experts to evaluate the use of a list of conditions in the 75 percent rule. This testimony is based on the April 2005 report.

What GAO Found

As noted in the April 2005 report, GAO found that in fiscal year 2003 fewer than half of all IRF Medicare patients were admitted for having a primary condition on the list in the 75 percent rule. Almost half of all patients with conditions not on the list were admitted for orthopedic conditions, and among those the largest group was joint replacement patients. The experts IOM convened said that uncomplicated unilateral joint replacement patients rarely need to be admitted to an IRF, and GAO analysis suggested that relatively few of the Medicare unilateral joint replacement patients had comorbid conditions that suggested a possible need for the IRF level of services. Additionally, GAO found that only 6 percent of IRFs in fiscal year 2003 were able to meet a 75 percent threshold. GAO also found that IRFs varied in the criteria used to assess patients for admission, using patient characteristics such as functional status, as well as condition. The Centers for Medicare & Medicaid Services (CMS), working through its fiscal intermediaries, had not routinely reviewed IRF admission decisions to determine whether they were medically justified, although it reported that such reviews could be used to target problem areas. The experts IOM convened and other clinical and nonclinical experts GAO interviewed differed on whether conditions should be added to the list in the 75 percent rule. The experts IOM convened questioned the strength of the evidence for adding conditions to the list--finding the evidence for certain orthopedic conditions particularly weak--and some of them reported that little information was available on the need for inpatient rehabilitation for cardiac, transplant, pulmonary, or oncology patients. They called for further research to identify the types of patients that need inpatient rehabilitation and to understand the effectiveness of IRFs. There was general agreement among all the groups of experts interviewed that condition alone is insufficient for identifying appropriate types of patients for inpatient rehabilitation, since within any condition only a subgroup of patients require the level of services of an IRF, and that functional status should also be considered in addition to condition. GAO concluded that if condition alone is not sufficient for determining which types of patients are most appropriate for IRFs, more conditions should not be added to the list at the present time and the rule should be refined to clarify which types of patients should be in IRFs as opposed to another setting.