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Insights and Trends

IRF Final Rule Raises Important Concerns

On July 31, 2018, the IRF Final Rule was issued by the Centers for Medicare and Medicaid Services, which will take effect FY 2020. In addition to the updates to IRF payment rates and other measures designed to streamline care and reduce inefficiencies, one of the most important takeaways from the Final Rule relates to the removal of the Functional Independence Measure (FIM™) Instrument and Associated Function Modifiers from the IRF-Patient Assessment Instrument (PAI) and Refinements to the Case Mix Classification System.

As we stated before the rule was issued and as we communicated to CMS directly, we have serious concerns about the removal of FIM as the primary indicator of patient outcomes in inpatient rehabilitation care. Our concerns about the use of Quality Indicators (QI) for payment determinations relate to several factors, including the short length of time the Quality Indicators have been in use and the inconsistency of the measures. The Quality Indicators are new measures that were adopted for use in FY 2017. In addition to only one year of data included in these replacement measures, the limited analysis CMS has made available to stakeholders is insufficient evidence as to the data’s validity or reliability as a basis for payment purposes. In contrast, the longstanding FIMs have been used by the industry for over 30 years and CMS had 4 years’ worth of data prior to implementing the use of FIMs to define payments. Although Lifepoint recognizes and supports the ultimate objective to eliminate duplicative quality measures and data elements, this objective should not be achieved at the expense of creating new payment determinations based on data that has not yet proved its reliability or validity. In the year since the IRFs have been reporting the QIs, there has been industry confusion due to the different definitions and scales compared to the FIMs. We feel this is symptomatic of a need for reliable tools to connect future performance to historical performance when two different measurement systems are used to ensure continuity in ongoing care improvement activities. This bears much more scrutiny and attention than has been given yet and gives us reason for concern.

As a demonstration of our continued commitment to patient care quality and outcomes, we plan to continue to utilize the Performance Evaluation Model or PEM system to ensure that our programs (JV IRFs and ARUs in which we are providing contract rehabilitation services) are providing the highest level care to our patients, allowing them to achieve the most function possible via inpatient rehab and stemming the rate of avoidable hospital readmissions. PEM provides a thorough evaluation of a program’s performance by utilizing an algorithm that takes information about patient-specific outcome goals, functional improvement while in the rehab setting and length-of-stay efficiency, as compared to other programs within the UDS database that see similar patients or have a similar case mix index. We believe that striving toward strong PEM scores standardizes our efforts toward very strong patient care and will continue to have a positive effect on the patients we serve. PEM scores help our programs identify areas where they may be lagging, and address those issues. We encourage comprehensive and clear processes for monitoring the PEM. A long history of reliance on measurable functional improvement data and education on the PEM in our patient-focused care is at the heart of this effort and we believe it strongly benefits our patients.

To read the Final Rule in its entirety, go to:

The IRF coverage criteria changes listed above will be effective in FY 2020; that is, for all IRF discharges beginning on or after October 1, 2019.

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