In a recent episode of Scrubs, the popular television sitcom about a group of quirky resident physicians working in a hospital, the main characters are faced with an interesting situation: The truculent chief of medicine admits one of his own friends for medical treatment and surgery; little does he know that his friend does not have health insurance. The residents go through a comical interlude of explaining how they can get away with treating a patient with no insurance, which is considered to be a taboo by the chief of medicine himself, who always puts the business interests of the hospital above the interests of any patients. In the comical sequence, the main characters find a file of a deceased patient, make sure this patient has just recently passed away so that the insurance hasn't quite been canceled yet, and use this deceased patient's name and information for the chief of medicine's newly admitted friend. For this, they need cooperation (through bribery) with the nursing staff, the insurance claims processing staff, etc. While this is a fictional example, I don't doubt that some medical professionals sometimes pull extreme strings to work around the insurance/reimbursement noose.

I saw this episode as I was putting my thoughts together for this column about recent news stories I have come across that highlight how payment dictates treatment. There is a current growing trend of nursing homes being the new "go-to" option for seniors to receive necessary physical and occupational therapy for conditions that are not reimbursed for in rehabilitation hospitals. The articles claim that nursing homes are stepping in to fill the "rehab gap" due to federal reimbursement changes, specifically the so-called "75-percent rule."

The "75-percent rule" is named for the requirement that 75% of specialty hospital rehabilitation patients should come from just 12 serious conditions, including stroke, spinal-cord injury, amputation, burns, and neurological conditions. As a result, this rule limits the number of patients the hospital can treat for common problems, such as hip and knee replacements, encouraging these patients to seek short-term rehabilitation elsewhere. Nursing homes see rehabilitation patients as a growing share of the market—they view short-term rehabilitation services as a way to fill beds and provide revenue that had been reduced as more people began staying longer in assisted-living facilities or at home as they aged.¹ Consequently, nursing homes have been spending money to upgrade their rehabilitation equipment, and they promote themselves as being able to provide the same level of care as rehabilitation hospitals. Needless to say, rehabilitation hospitals are lobbying against the "75-percent rule," with the aim of delaying its complete implementation or having it overturned.

It is ideal to think that health care professionals always have the luxury of treating and helping any patient that walks into their facility. Rehabilitation hospitals—and practices—cannot stay in business without keeping costs in mind. In our October 2006 issue, we featured an article about the rehabilitation department of the Torrance Memorial Medical Center in Torrance, Calif. The rehabilitation team put time-saving initiatives into place that, in 1 year, increased patient visits per month from 838 to 1,057, accounting for an increase in gross revenue of more than $27,000 in a particular month. (Read the full article online in the online archives.) I would love to hear from our hospital-based PT readers—whether your facility is affected by the "75-percent rule" or not—about other solutions to improve business during a time of ongoing payment restrictions. I'll print the most interesting tips in the magazine.

Arati Murti

Reference:

1. Lerner J. Nursing homes step into rehab gap. Shreveporttimes.com. Available at: www.shreveporttimes.com/apps/pbcs.dll... Accessed July 25, 2007.