The real goal of geriatrics is fundamentally rehabilitative: to restore and/or maintain the maximum degree of independence possible for each older person. This is what every person, older or not wants: to be able to choose and do what he or she prefers to do, to be autonomous in daily living and in short-and long-range life choices
Often lost in the raging public policy debates regarding health care financing is the simple reality expressed decades ago by the former Director of the National Institute on Aging, Dr. T. Franklin Williams, that the essence of geriatric medicine is rehabilitative, helping individuals restore function and/or prevent further deterioration.
There is little on the Federal public policy horizon that reflects an appreciation of this fundamental principle. Indeed, while we have secured a short term reprieve through the end of 2012 on several of the more contentious issues regarding professional fee schedules and the Part B therapy cap, the "Sword of Damocles" swings over our head.
When Congress enacted Public Law 112-96 (Middle Class Tax Relief & Job Creation Act of 2012) in February, it extended protections through the end of 2012 preventing a collapse of the Medicare professional fee schedules (Section 3003 of H.R. 3630). The enactment also extended the Part B Therapy Cap exceptions process but added additional coding constraints and a second tier cap triggering additional medical review. For over a decade, meaningful resolution of both issues has been elusive.
There is a real need for rehabilitation professionals to be attentive to the several ideas which have been advanced to "fix" the Medicare professional fee schedules. To date, most ideas that have been advanced focus exclusively on the physician component of the fee schedules, and they are silent on what happens to non-physician professional services linked to the fee schedules. Several of the proposals that have floated have proposed establishing multiple "conversion factors" with payment varying based on the definitions. Likewise, there is need to be anxious that Congress acts to at least extend the status quo, as without remedial legislation by the end of the year, professional fee schedules could be reduced by over 30% (proposed CY13 Medicare Professional Fee Schedule rules are expected to be release in late June with a 60 public comment period).
The rhetoric surrounding the extension of the Part B Therapy Cap exceptions process gives pause that further constraints might be forthcoming. Suspicions of over-utilization were voiced; another layer of medical review has been enacted, and the Medicare Prospective Payment Advisory Commission has been asked to make its recommendations.
While these actions focus on Medicare Part B therapy utilization, CMS is poised to review and make recommendations to revise payment methodologies under Medicare Part A for rehabilitation services delivered to skilled nursing facilities patients. A number of CMS medical and fraud/abuse contractors are not waiting for the facts to be examined and the regulations revised, they are aggressive promoting their investigative authorities adding pressures on caregivers.
Collectively our professions confront the challenge to stay focused; to do what is professionally correct; to what is right for the patient; to be active participants in the care team; to communicate clearly the value of our intervention and the goals that we are attempting to achieve; and to be responsive in our documentation.
It is equally incumbent for us to help educate the public and our elected officials about the value of rehabilitation and the very important role nursing homes perform in delivering meaningful interventions. Data affirms that 11 million Medicare beneficiaries were successfully discharged from the acute setting in 2010. Of those discharged, two out of five (39%) required post-acute interventions. One in ten (10%) of those requiring follow-through were treated in an outpatient rehabilitation center. Nearly one in ten (9%) were treated in inpatient rehabilitation facilities (IRFs). Most, eight of ten were discharged to skilled nursing facilities and/or home care with skilled nursing facilities serving the largest percentage (42%) of post-acute discharges. Indeed, adjusted by age, the percentage of post-acute admissions to SNFs increased dramatically.
We are in a battle of perceptions verses facts. The facts are on our side and we need to be articulate in moving the debate from the "ten-second" sound bites, to the reality that skilled nursing centers have become the predominate site for helping restore function and to prevent further deterioration in activities of daily living. We are making a difference for those that we care for and we should not shy away from aggressively promoting this reality.