Quality care in the new era of PPSs.

Abstract

Susan Dean-Baar, PhD RN CRRNFAAN Editor We are on the brink of a new era in rehabilitation. Eighteen years after diagnosis-related groups (DRG) were instituted as the basis for payment for acute hospital services, a prospective payment system (PPS) will be used by Medicare to pay for inpatient rehabilitation services. The Health Care Financing Administration (HCFA) identified a set of laudable objectives for development of the PPS for inpatient rehabilitation facilities. The objectives outlined in the proposed rules for the PPS included the (a) creation of a beneficiary-centered payment system that promotes quality of care, access to care, and continuity of care, and is administratively feasible while controlling costs; (b) provision of incentives to furnish services as efficiently as possible without diminishing the quality of care or limiting access to care; (c) creation ofa payment system that is fair and equitable to facilities, beneficiaries, and the Medicare program; and (d) recognition of legitimate cost differences among settings and group patients and services in clinically coherent categories that reflect similar resource use. It will be no small feat to accomplish all these objectives. The concern among rehabilitation providers is that the cost concerns will eventually win out in the struggle between the goals to control costs and the goals related to promoting quality and access to care. Ofcourse, HCFA is concerned about the potential for providers to "upcode" and "game" the system. There is sometimes a fine line between knowing the rules of the game to legitimately maximize the amount of payment received for services provided rather than to inflate the amount ofpayment received. Although the providers who play the game to inflate the payment are few in comparison to the rest of the field, they do exist in enough numbers to make it a realistic concern for HCFA, as evidenced by the fraud cases that make the news in increasing numbers. The tensionbetweengoalsofqualityandaccess and goals of cost containmentis certainly not new to rehabilitation. We began to feel it when the inpatient acute providers began to discharge patients quicker and sicker to rehabilitation settings. The Balanced Budget Refinement Act of 1999 requires implementation ofan inpatient rehabilitation PPS this year.As a result, the payment system that is implemented may not accurately reflect the actual costs of providing services. This is especially true in that the historic data used to project costs probably don't accurately reflect staff time resource use within the case mix groups. Although studies of staff time measurement have been conducted, the data were not available in time to include in the determination of the initial system. In addition, many arguments have been made that the current PPS for inpatient acute care does not adequately cover the costs of providing care, which leads to the early discharge of acute patients to other levels of care. As a result, the new system is likely to increase the tension between the goals ofquality, access, and cost containment. As nurses we are likely to be right in the middle of that tension. HCFA is exploring the development ofquality indicators in areas such as level of functional independence at discharge, incidence of pressure ulcers, incidence of falls, and development of facility quality improvement programs, in order to guard against a decrease in the quality ofcare provided. We need to be prepared to advocate strongly for development of rehabilitation programs within our own organizations and institutions that find the right balance between providing accessible, quality care and staying within the constraintsof the new PPS. We will need to be vigilant that nursing does not become a target for cost-cutting measures that substantially decrease access to quality rehabilitation for Medicare beneficiaries. PPS is finally here for rehabilitation. Our professional obligation is now to participate in creating systems that will allow the true achievement of the goals set forth by HCFA, and not to allow the only goals achieved to be those related to cost.