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Medicare 75% Rule Maintains Quality Rehabilitative Services for Seniors, Saves Tax Dollars

Attempt to Delay Full Implementation Disregards Government Data, Ignores Proven Facts

Washington, DC –As the debate in Congress regarding the so-called “Medicare 75% Rule” intensifies, the Alliance for Quality Nursing Home Care today said that  an effort to scale back full implementation of this key provision is the wrong move for seniors and for taxpayers.

“At a time when lawmakers are rightly assessing spending priorities on a variety of fronts, it is more important than ever to ensure ‘quality’ and ‘cost-efficiency’ are the two key drivers of public policy decision-making,” stated Alan G. Rosenbloom, President of the Alliance. “By every legitimate measure, delaying or blocking full implementation of the Medicare 75% rule would turn back the clock on the urgent need to strengthen our health care system to ensure seniors receive quality rehabilitative care in the most appropriate setting and at the lowest cost to taxpayers,” he continued.

The “Medicare 75% Rule,” when fully implemented, will require that only 75% of patients receiving care in inpatient rehabilitation facility (IRF) need very intensive rehabilitation services.  If an IRF satisfies this requirement, then all of its Medicare patients would qualify for Medicare payments that are substantially higher than rates paid to skilled nursing facilities (SNFs). Currently, only 65% of patients must meet the criteria.  Typically, Medicare patients receive rehabilitation care following a hospital stay in either an IRF or a SNF.   The rule was crafted to ensure Medicare beneficiaries receive rehabilitative care in the most appropriate and cost-effective setting for their needs. 

Before implementation of the rule began, IRFs were treating many patients who could receive the same quality care in SNFs.  The rule effectively differentiates the truly high acuity patients who need intensive rehabilitation services provided in a hospital setting from those who could be cared for in SNFs and other settings at the same high level and quality -- and at a significantly lower cost to the Medicare program.

A report issued in early 2007 by the Centers for Medicare and Medicaid Services (CMS) specifically supports government plans to continue moving toward full implementation of the 75 percent rule. According to CMS, the data illustrate that: "Ongoing implementation of the 75 percent rule continues to have the desired effect of ensuring that the most appropriate Medicare beneficiaries have access to care in IRFs, while those with lower acuity cases are increasingly being served in settings that are both less intensive and less costly."

The CMS report also says that that the categories of patients being directed from IRFs to lower cost settings include those receiving care for lower extremity joint replacement, cardiac rehabilitation, osteoarthritis, and pain syndrome. "These categories are associated with conditions that are not generally considered to require the intensive rehabilitation provided by IRFs and can often be more appropriately cared for in other less intensive settings," the report said. "SNFs, particularly, are in a better position than ever before to manage patients with musculoskeletal conditions .... [these] are precisely the patients who may need some level of medical monitoring but do not require the intense level of services provided in an IRF setting."

The Health and Human Services (HHS) Office of Inspector General (OIG) also issued a report in June, 2007 (“Consecutive Medicare Stays Involving Inpatient and Skilled Nursing Facilities”) explaining how full implementation of the 75% Rule is the best way for the federal government to help preserve Medicare beneficiary access to quality care at the lowest, most cost-effective rate.  

Concluded Rosenbloom: “Proceeding as planned with full implementation of this important Medicare rule would be highly beneficial to U.S. seniors, taxpayers, our eldercare system and for the bottom line principle of accountability and quality care. Conclusive data and facts should be the ultimate drivers of policy.”  

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