steve m. gnatz, md, mha chief medical officer integrated rehab consultants professor, physical...

Steve M. Gnatz, MD, MHAChief Medical OfficerIntegrated Rehab ConsultantsProfessor, Physical Medicine and RehabLoyola University Medical Center

The Role of Large Systems for Integration of Services in Subacute Rehabilitation

Dr. Gnatz is contracted with, and paid a stipend for, his role as: Chief Medical Officer Integrated Rehab Consultants, LLC

Financial Disclosure

There is always strength in numbers. The more individuals or organizations that you can rally to your cause, the better.

Mark Shields

U.S. aging population 1900-2050

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 20500

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

80,000,000

90,000,000

100,000,000

Population 65+ by Age: 1900-2050Source: U.S. Bureau of the Census

Age_x000d_65-74 Age_x000d_75-84 Age_x000d_85+

Num

ber o

f Per

sons

65+

By 2030, there will be only 3 people working for each “retired” person.

Source: Medpac 2015 report to Congress

“Over 65” age group 2000 -2010 grew 15% (35M to 40.2M)Medicare expenditures for PAC services 2000-2010 DOUBLED (29B to 58B) Medicare expenditures for PAC services 2010-2013 FLAT (1%)

U.S. aging population and PAC growth 2000-2010

Growth

0

50

100

150

200

250

IRF

SNF

Percentage Medicare expenditure growth in IRF v SNF payments 2001-2013

SNF = 211%Increased # cases, Increased cost per case

IRF = 144%Decreased # casesIncreased cost per case

Source: Medpac report to Congress 2015

Payment per case in IRF explains the increase in IRF expenditures 2004-2013

2005 20140

2000

4000

6000

8000

10000

12000

14000

16000

IRFLinear (IRF)SNFLinear (SNF)

Number of IRF v SNF Facilities 2005-2014

Source: Gelman LTC Billing 2014 - based on CMS data

2004 20130

1000000

2000000

3000000

4000000

5000000

6000000

7000000

PM&R Billable Days

SNFLinear (SNF)IRFLinear (IRF)

Estimate of net loss for physiatry of 1.4 M billable patient days in IRF vs. gain of only 236,500 in SNF

Assumptions:1 15,000 SNF’s 2 Average Bed Size of 117 (1,755k Total Beds)3 20% in Active Rehab (351k Rehab Cases)4 Average Medicare LOS 37 days (13M Bed Days)5 Physiatrist sees each active rehab patient 10 times

over an average LOS (3.5M visits)6 Each physiatrist can see 30 patients/day (1,115

visits per average 37 day LOS)

How many physiatrists would be needed if every patient in active rehab in a SNF had one?

3,136 Full-Time

SNF vs. IRF cost - comparing apples to oranges?

• The 60% rule has restricted some non-compliant patients from going to IRF’s.

• Local Coverage Determinations (LCD’s) specify subacute rehab for certain diagnoses.

• Medicare Advantage (managed care) and private insurers may direct site of PAC for some diagnoses.

• Subacute rehab has been shown to be less costly for some diagnoses.

• Subacute providers recognizing the need for physiatry directed, short-stay rehab programs in a SNF environment.

What is fueling the movement of rehab patients to subacute?

The choice of PAC provider is determined by what is available – not by what is ideal.

Source: Examining Post Acute Care Relationships in an Integrated Hospital System - RTI February 2009

Trends to watch in PAC:

Readmission penalties Started with few diagnoses (CHF, PNA), more to come Hospital 2013, SNF 2018

Bundled Payments Acute hospital and Post-acute combined

Unified PAC Payment System (Site Neutral) Payment based on Diagnosis modified by Complications

and Comorbidities Unified Functional Outcome Measure

CARE Tool

PAC Reforms Coming…

SNF’s will continue to try to differentiate themselves and their programs

Most Advanced Post Hospital Rehabilitation

Comfort

Amenities

State of the Art Equipment

Most Prestigious Physicians and Hospitals

Staffed 7 days a week – 20 FT Therapists on Staff

Independent Living

Discharge Planning with home visit

Private Room with ensuite accessible Bathroom

Looks like a 4 Star Hotel

Spa and Salon Services

Transport to Doctor Appointments

Outings

Wifi Internet

Offering top post acute clinical programs:

Our comprehensive list of medical programs assure the quickest recoveries and reduced 30-day re-hospitalizations.

Homeward Bound. Sub acute rehabilitation program with medical leadership by physicians specializing in physical medicine and rehabilitation focused on returning patients home as quickly as possible.

S.T.A.T. Program. Stabilize. Treat. Assess. Transition – Enhanced physician and nursing oversight and management for the prevention of unnecessary hospitalizations.

O.R.T.H.O. Optimal Rehabilitation and Treatment with Healthy Outcomes. Orthopedic recovery and rehabilitation program for patients post joint replacement or fracture.

“Don’t let the hospital discharge planner take your power away.”

Aging Baby Boomers will demand control of their post-acute care services.

Source: Genesis Health Care System

A group of 65 (and growing) physiatrists who practice in a subacute (SNF) environment

A physician-owned organization dedicated to providing a higher level of post-acute care, allowing physicians the opportunity to work for themselves while having the backing of a national organization

IRC partners physiatrists with skilled nursing facilities to provide enhanced levels of care for rehab patients in a post-acute setting

Based in Chicago, Illinois with 172 locations across the US

What is Integrated Rehab Consultants?

IRC STATESArizonaCaliforniaColoradoConnecticutFloridaIllinoisIndianaMarylandMissouriNew YorkNorth CarolinaOhioOregonPennsylvaniaSouth CarolinaTexasVirginiaWisconsin

Provide locations to practice Centralized credentialing and privileging Clinical protocols and pathways Clinical documentation and coding tools Provide centralized billing and collecting Auditing of billing and coding with feedback Provide PQRS and MU data collection & support Centralized malpractice insurance Marketing and professional development support

What does IRC do for physiatrists?

With the changing landscape of healthcare more patients will be pushed to post-acute levels of care than ever before  

Healthcare systems will be focused on clinical outcomes and preventing readmissions

Partnering with IRC brings increased clinical documentation along with expert levels of post-acute rehab care

Assist with new program development and clinical protocols

Marketing to local referral sources We don’t promise to “deliver patients”!

What does IRC do for SNF’s?

“Since Dr. Tariq from IRC started at my facility, the results have been amazing! In just six months of working with him on key areas to improve, the number of patients we treat for rehabilitation increased from 29.2% to 37.2%, our return to hospital decreased from 21% to 15%, RU% went from 63% to 74% and best of all our CMS Quality of Patient Care Star Rating for pain went from a 2 to 3 because of his close monitoring and staff education on pain reported by our short term and long term patients.” L.D, Executive Director at Indiana SNF

Anecdotal results

Provide a scarce physician resource (physiatry) Provide data on how our model affects:

Return to Home or Community Functional Outcomes Return to Hospital Patient Satisfaction Pain Control Length of Stay Medicare Star Rating Documentation for RAC and other audits Therapy Certification (compliance rate)

Liaison to solve problems and maintain satisfaction

How does IRC integrate into large systems?

Physiatry, Rehabilitative Medicine (026) – A physiatrist, or physical medicine and rehabilitation specialist, is a medical doctor trained in the diagnosis and treatment of patients with physical, functionally limiting, and/or painful conditions. These specialists focus upon the maximal restoration of physical function through comprehensive rehabilitation and pain management therapies. Physical Therapists are NOT Physiatry/Rehabilitative Medicine physicians and are not to be included on the MA Provider tables under this specialty type.

Source: CMS CY2015 Medicare Advantage Provider and Facility Specialties and Network Adequacy Criteria Guidance

Physiatry is not Physical Therapy

Consult PM&R for patients: with impaired physical and/or cognitive function in active

rehabilitation - especially those where coordination of the multidisciplinary team is needed and especially for those where the anticipated discharge destination is home.

who are in specialized programs or by rehab diagnosis - spinal cord injury, TBI, cardiopulmonary, stroke, orthopedic, amputee, LVAD, cancer, etc.

with reduced function due to spasticity, focal or generalized weakness, loss of sensation, pain, or cognitive issues.

with specialized adaptive equipment or DME needs - prosthetics and orthotics, specialized wheelchairs or powered mobility devices, or other specialized adaptive equipment needs.

with pain management issues, particularly musculoskeletal pain - including, but not limited to, medication recommendations, therapy recommendations, joint injections, etc.

who fall - or have significant risk of falling.

Physiatry consult in admitting order sets for certain diagnoses or by request (nursing, therapy, physician)

Rounding on patients in active rehab 2-3x/week Participating in “Medicare” or other multi-disciplinary

meetings regularly Interaction and problem solving with the therapy staff Working with the SNF Medical Director and/or

administrator to address quality issues or facility-wide problems (e.g. falls)

Document functional progress (or lack thereof) and facilitate level of care transitions

Patient and family education about rehab issues

How does IRC physiatry integrate into facilities of large systems?

I don’t want physiatry in my facility, they will just drive up the cost.

I’m not sure that I will get paid by Medicare if you bill the same day on the same patient.

I just let the PT decide when my patient should be discharged.

You’re the pain doctors, right? You should write all the narcotic prescriptions for my patients then.

(To the nurse) Just send Mrs. X back to the hospital. I’m too busy to come and take a look at her.

Goofy things we’ve heard from SNF Medical Directors and primary care physicians along the way…

Physiatry belongs, and has a role in, all levels of post-acute care (IRF, LTAC, SNF, HHC, OP)

When we attend our patients in a sub-acute (SNF) environment today, they have similar characteristics to those we would have seen in an IRF a few years ago

Practicing in a SNF environment can be satisfying and challenging

Functional outcomes should trump cost-cutting in rehab, but being aware of cost-effectiveness will serve us well

IMHO

Physiatrists are expert trained “integrators” in PAC Patients in all PAC settings will benefit from better

integrated care Demographics of the aging population will result in

continued pressure to be more cost effective in PAC Providers are consolidating into larger systems of

care Larger systems need care integration just as much (if

not more) than smaller ones Larger systems depend more on “hard-wired” care

integration (protocols, pathways, etc.) Sharing risk will mean that the onus will become even

stronger to coordinate and integrate care in PAC

The bottom line:

Questions?