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

Fewer than half of all IRF Medicare patients in fiscal year 2003 were  admitted for conditions on the list in the 75 percent rule. The largest group of  patients admitted for orthopedic conditions not on the list were admitted  for joint replacements that did not meet the list’s specific criteria for joint  replacement. Relatively few of these patients had comorbid conditions  that suggested a possible need for the intensive level of rehabilitation  provided in IRFs. Additionally, we found that based on the fiscal year 2003  data few IRFs were able to meet a 75 percent threshold. Medicare Patients Admitted to IRFs in 2003 Had Variety of Conditions

Medicare patients were admitted to IRFs in fiscal year 2003 with a variety  of conditions, as defined by the impairment group codes we analyzed. 2.) IRFs Vary in the Criteria Used to Assess Patients for Admission, and CMS Does Not Routinely Review IRFs’ Admission Decisions

The criteria IRFs used to assess patients for admission varied by facility,  and CMS has not routinely reviewed IRFs’ admission decisions. In  particular, IRFs used a range of criteria in making admission decisions,  including patient characteristics such as function, in addition to condition. Experts Differed on Adding Conditions to List in Rule but Agreed That Condition Alone Does Not Provide Sufficient Criteria

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  the types of patients appropriate for IRFs. They reported that the evidence on the benefits of IRF services— particularly for certain orthopedic conditions—is variable, and they called  for further research. Other experts did not agree on whether conditions,  including a broader category of joint replacements, should be added to the  list. Experts IOM Convened Questioned Evidence for Adding Conditions to List in Rule, Finding Evidence for Certain Orthopedic Conditions Particularly Weak, and Called for More Research

The experts IOM convened generally questioned the strength of the  evidence for the conditions suggested for addition to the list in the rule. Experts Contended That Functional Status, in Addition to Condition, Should Be Used to Identify Appropriate Types of Patients for Intensive Inpatient Rehabilitation

The experts IOM convened contended that condition alone was  insufficient for identifying which patients, or types of patients, required  the level of services available in an IRF and generally agreed that  functional status should also be used. In addition to the experts convened by IOM, other experts we interviewed  also said that condition alone was insufficient because having a condition  on the list in the rule does not automatically indicate the need for intensive  inpatient rehabilitation (e.g., even though stroke is on the list, only a  subgroup of stroke patients require IRF services) and having a condition  not on the list does not necessarily mean the patient does not need IRF  services (e.g., although there is no cardiac condition on the list, a  subgroup of cardiac patients need the level of services of an IRF). The names of other staff  members who made contributions to this report are listed in appendix V.

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. 3. 6. 13. We  conducted our analyses on Medicare patients only because CMS records  contained data on the largest number of IRFs and the majority of patients  in IRFs are covered by Medicare.
Why GAO Did This Study

Medicare classifies inpatient rehabilitation facilities (IRF) using the "75 percent rule." If a facility can show that during 1 year at least 75 percent of its patients required intensive rehabilitation for 1 of 13 specified conditions, it may be classified as an IRF and paid at a higher rate than is paid for less intensive rehabilitation in other settings. Medicare payments to IRFs have grown steadily over the past decade. In this report, GAO (1) identifies the conditions--on and off the list--that IRF Medicare patients have and the number of IRFs that meet a 75 percent threshold, (2) describes IRF admission criteria and Centers for Medicare & Medicaid Services (CMS) review of admissions, and (3) evaluates use of a list of conditions in the rule. GAO analyzed data on Medicare patients (the majority of patients in IRFs) admitted to IRFs in FY 2003, spoke to IRF medical directors, and had the Institute of Medicine (IOM) convene a meeting of experts.

What GAO Found

In fiscal year 2003, fewer than half of all IRF Medicare patients were admitted for having a condition on the list in the 75 percent rule, and few IRFs admitted at least 75 percent of their patients for one of those conditions. The largest group of patients had orthopedic conditions, not all of which were on the list in the rule, which had been suspended in 2002. 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. Although some joint replacement patients may need admission to an IRF, GAO's analysis showed that few of these patients had comorbidities 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. IRFs varied in the criteria used to assess patients for admission, and CMS has not routinely reviewed IRF admission decisions. IRF officials reported that the criteria they used to make admission decisions included patient characteristics such as function, as well as condition. CMS, working through its fiscal intermediaries, has not routinely reviewed IRF admission decisions. 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 but agreed that condition alone does not provide sufficient criteria to identify the types of patients appropriate for IRFs. 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 they called for further research to identify the types of patients that need inpatient rehabilitation and to understand the effectiveness of IRFs. Other experts did not agree on whether conditions, including a broader category of joint replacements, should be added to the list. Experts, including those IOM convened, generally agreed 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 contended that functional status should also be considered.