By On July 18th, 2014

Will Revising the 60 Percent Rule Reduce Long Term Brain Injury Outcomes By 60 Percent?

In a perfect world all treatment options for brain injuries would be equal and available for patients in need. Unfortunately that is often not the case. Individuals with brain injuries in need of rehabilitation are often placed in treatment facilities based on availability, but these  treatment options can vary drastically in effectiveness and likelihood for positive outcomes.

CoupleinIPRehabCurrently, the standard for brain injury treatment is set by inpatient rehabilitation facilities (IRFs). These facilities offer treatment under the direction of a physician trained in rehabilitation medicine and specialized nursing staff. They use structured, focused, and time sensitive care plans specifically designed to maximize positive outcomes.

Availability to IRFs is defined by a rule often known as the “60 Percent Rule”, which stipulates that to qualify for Medicare payment under the IRF prospective payment system (PPS) at least 60 percent of an IRFs admissions in a single cost reporting period must be in one or more of 13 clinical conditions – one of which is brain injury.

While this rule currently ensures access for some individuals with brain injury in IRFs, it also causes some Medicare beneficiaries with conditions previously treated in IRFs to be treated in alternative facilities such as skilled nursing facilities (SNFs).

When compared to IRFs, SNFs care plans leave considerable room for improvement. Due to limited availability of an onsite physician and no regulatory rehabilitation standards, treatment plans offered by SNFs vary dramatically and typically provide lower intensity rehabilitation.

The differences between IRFs and SNFs are not limited to the form of treatments. In light of proposals to expand the 60 Percent Rules to equate IRFs and SNFs, primarily aimed at minimizing Medicare costs, a team of researchers from Dobson DaVanzo & Associates enacted a study to assess the quality of treatment offered by these facilities and the outcomes they produce. The difference in outcomes for individuals with brain injury is significant.

People who experienced brain injuries spent longer in SNFs compared to the average length of stay in IRFs, but the long-term outcomes were worse. Patients treated in skilled nursing facilities showed increased mortality rates two years after treatment and notably shorter lifespans overall. The report also revealed that individuals with brain injury treated in IRFs had less ER visits and hospital readmissions per year.

When taken together, these findings make it clear that people with brain injuries treated in skilled nursing facilities experience significantly decreased quality of life with a compelling decrease in lifespan and more frequent medical needs.

While the 60 Percent Rule ensures some availability of treatment in IRF facilities, its implementation actually decreased the number of patients treated in inpatient rehabilitation facilities. If the policy is revised to equate inpatient rehabilitation facilities and skilled nursing facilities, it is likely to further decrease the number of patients treated in IRFs. It is safe to say it will also decrease the likelihood of positive outcomes for those who have experienced brain injuries.

As the report states, “patients redirected from the IRF to the SNF in an attempt to reduce Medicare payments for the initial rehabilitation may suffer diminished patient outcomes that impact their quality of life”.

On top of the issue of real and significant impacts for individuals with brain injuries, the findings also suggest revising the policy would not be financially effective either. While there may be short term savings, it is likely these savings will not be experienced for long before greater medical costs are found due to more frequent emergency room visits and hospital readmissions.

Brain injuries are one of the few conditions contained in the 60 Percent Rule which experienced an increase in IRF admissions following the implementation of the policy due to the severity of the condition. The current state of the policy is intended to prioritize IRF access based on condition severity, but if it is revised to equate IRFs and SNFs with a goal to minimize costs, all signs indicate these increases will regress as short term savings would favor treatment in SNFs at the cost of life quality and long-term costs.

In the end, revising this policy would likely not accomplish any of the goals intended. Not only are long-term costs not likely to be significant due to increased long-term medical needs, but the revision would also create a system that rations care to appropriate high-quality treatment in an attempt for short-term savings.

Policy-makers tend to think in terms of dollars and cents when it comes to revisions such as the proposed changes to the 60 Percent Rule, but in this case the outcome simply doesn’t make sense. It would create lower-quality outcomes for individuals with a real need for quality treatment, but it wouldn’t create any savings.

The disparity in treatment options and their associated outcomes for individuals who have experienced debilitating injuries such as brain injury can be the difference between an independent and fulfilling life and one of dependence and sustained medical problems. There should never be a system which favors a lower quality treatment for conditions like these, especially when time is important in defining the success of treatments.

Inpatient rehabilitation facilities offer the highest quality treatment and measurably improved outcomes and should continue to be available to those who would most benefit from this kind of focused treatment and continued so long as these individuals are able to benefit from these treatments.

No matter how tight budgets get, the need for quality care and positive outcomes should always matter more than financial savings, but even those who are able to think of individuals in dire need for medical care as data points should be able to see the revised policy is just a bad deal.


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