Rehabilitation and Regenerative Medicine

PM&R in Subacute Rehabilitation: Attending Physician or Consultant?

Joel Stein, MDSimon Baruch Professor and Chair

R e h a b i l i t a t i o n a n d R e g e n e r a t i v e M e d i c i n e

Disclosures

• None specifically related to this presentation• Research support from Nexstim, Tibion,

Myomo, Tyromotion• Member of Scientific Advisory Board -

Myomo, Inc. (uncompensated)

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PM&R Physician Role in IRF• CMS: “Require physician supervision by a

rehabilitation physician, with face-to-face visits at least 3 days per week to assess the patient both medically and functionally and to modify the course of treatment as needed”• Daily physician visits 5-7 days/week are

typical

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PM&R Residency Requirements (ACGME)

• Residents must have direct and complete responsibility for the rehabilitative management of patients on the inpatient PM&R service.• Each resident responsible for a minimum of

6 – 14 inpatients (average of 8).• Residents should have inpatient rounds to

evaluate patients with faculty members at least five times per week.

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SNF regulations• Initial MD visit within 30 days of admission,

and at least once every 30 days for the first 90 days after admission.• Physician orders needed for medications on

admission

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Financial Aspects – E&M• Medicare: SNF 99306 Admission (highest

level) NYC $188 vs. Hospital 99223 (highest level) $230• Mid-level follow-up care SNF SNF 99308

($77) and 99309 ($103) vs. Hosp 99232 $82• Systems are less supportive and less

efficient than hospital; resulting in lower billable visits/day. • 1 new admit and 9 f/u’s/day = c. $230K

direct revenues annually

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Patient Mix

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Physician Satisfaction?

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Drawbacks to SNF Attending Role• Lower reimbursements than IRF• Less likely to receive Medical Director Stipend• Non-Teaching environment•Weaker infrastructure•Weaker night/weekend coverage systems•Weaker relationships with each patient•More non-billable care, worse payor mix•More medical/less rehab oriented diagnostic

mix

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Conclusions• There are good reasons why physiatrists

have been reluctant to assume primary attending responsibility in SNF’s/Subacute Rehabs• If IRF care shrinks, PM&R may find itself

marginalized in post-acute rehabilitation unless we shift our paradigm