The unmet need for postacute rehabilitation among medicare observation patients: A single-center study
BACKGROUND
Medicare beneficiaries admitted under observation status must pay for postacute inpatient rehabilitation (PAIR) services, out of pocket, at potentially prohibitive costs.
OBJECTIVE
To determine if there is an unmet need for PAIR among Medicare observation patients and if this care is associated with longer hospital stay and increased rehospitalization.
DESIGN/SETTING
Observational study using electronic medical record and administrative data from a regional health system.
PATIENTS
1323 community-dwelling Medicare patients admitted under observation status.
MEASUREMENTS
Summary statistics were calculated for demographic and administrative variables. Physical therapy (PT) and case management recommendations for a representative sample of 386 medical records were reviewed regarding need for PAIR services. Linear regression was used to measure the association between PT recommendation and hospital length of stay, adjusting for ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis, age, sex, and provider. Chi-square test was used to determine the association between PT recommendation and 30-day hospital revisit.
RESULTS
Of the 1323 study patients, 11 (0.83%) were discharged to PAIR facilities. However, 17 (4.4%) of the 386 patients whose charts were reviewed received a recommendation for this care. Adjusted mean hospital stay was longer (P < 0.001) for patients recommended for rehabilitation (75.9 h) than for patients with no PT needs (46.8 h). In addition, the 30-day hospital revisit rate was higher (P = 0.037) for the patients who had been recommended for rehabilitation (52.9%, 9/17) than for those who had not (25.4%, 30/118).
CONCLUSIONS
Medicare observation patients’ potential need for PAIR services is 5- to 6-fold higher than their use of these services. Observation patients recommended for this care may have worse outcomes. Journal of Hospital Medicine 2017;12:168-172. © 2017 Society of Hospital Medicine.
© 2017 Society of Hospital Medicine
As the US population ages and becomes increasingly frail, the need for rehabilitation rises. By 2030, an estimated 20% of the population will be 65 years old or older, and almost 10% will be over 75.1 About 20% of hospitalized Medicare patients receive subsequent care in postacute inpatient rehabilitation (PAIR) facilities, accounting for $31 billion in Medicare expenditures in 2014.2 Although the need for rehabilitation will continue to rise, Medicare policy restricts access to it.
Under Medicare policy, PAIR services are covered for certain hospitalized patients but not others. Hospitalized patients are either inpatients, who are billed under Medicare Part A, or outpatients, billed under Part B. When hospital length of stay (LOS) is anticipated to be less than 2 midnights, patients are admitted as outpatients under the term observation status; when longer stays are expected, patients are admitted as inpatients.3 This recently implemented time-based distinction has been criticized as arbitrary, and as potentially shifting many patients from inpatient to outpatient (observation) status.4
The distinction between inpatient and observation status has significant consequences for posthospital care. Medicare Part A covers care in skilled nursing facilities (SNFs) and acute inpatient rehabilitation facilities (IRFs); after hospitalization, inpatients have access to either, without copay. As observation patients are covered under Medicare Part B, they are technically not covered for either service after their hospital stay. IRFs sometimes accept patients from ambulatory and nonacute settings; observation patients may be accepted in rare circumstances, but they pay the Part A deductible ($1288 in 2016) to have the services covered by Medicare. SNF services are never covered for observation patients, and access to this care requires an average out-of-pocket payment of more than $10,503 per beneficiary for a typical SNF stay.5 Given that about 70% of Medicare patients fall below 300% of the federal poverty line,6 the out-of-pocket costs for PAIR services for observation patients can be prohibitive.
Although only 0.75% of community-dwelling Medicare observation patients are discharged to PAIR facilities,7 it is unclear if the need for this care is higher but remains unmet secondary to cost concerns of Medicare beneficiaries. Also unclear is whether observation patients who would benefit from this care but do not receive it end up with poorer health outcomes and therefore use more healthcare services.
The purpose of this study was to estimate the proportion of Medicare observation patients who are admitted from home and receive a recommendation for placement in a PAIR facility, and to determine the ultimate disposition of such patients. We also sought to evaluate the association between recommendation for PAIR placement, LOS, and 30-day hospital revisit rate.
