Implementation Of Prospective Payment System Research Articles

Effect of End-Stage Renal Disease Prospective Payment System on Utilization of Peritoneal Dialysis in Patients with Kidney Allograft Failure.

The Center for Medicare and Medicaid Services (CMS) introduced an End Stage Renal Disease (ESRD) Prospective Payment System (PPS) in 2011 to increase the utilization of home dialysis modalities, including peritoneal dialysis (PD). Several studies have shown a significant increase in PD utilization after PPS implementation. However, its impact on patients with kidney allograft failure remains unknown. We conducted an interrupted time series (ITS) analysis using data from the United States Renal Data System (USRDS) that include all adult kidney transplant recipients with allograft failure who started dialysis between 2005 and 2019. We compared the PD utilization in the pre-PPS period (2005-2010) to the fully implemented post-PPS period (2014 - 2019) for early (within 90 days) and late (91-365 days) PD experience. 27507 adult recipients with allograft failure started dialysis during the study period. There was no difference in early PD utilization between the pre-PPS and the post-PPS period in either immediate change (0.3% increase; 95%CI: -1.95%, 2.54%; p=0.79) or rate of change over time (0.28% increase per year; 95%CI: -0.16%, 0.72%; p=0.18). Subgroup analyses revealed a trend toward higher PD utilization post-PPS in for-profit and large-volume dialysis units. There was a significant increase in PD utilization in the post-PPS period in units with low PD experience in the pre-PPS period. Similar findings were seen for the late PD experience. PPS did not significantly increase the overall utilization of PD in patients initiating dialysis after allograft failure.

Have racial disparities in home dialysis utilization changed over time?

The Medicare end-stage kidney disease (ESKD) prospective payment system (PPS) for maintenance dialysis, implemented in 2011, resulted in modestly increased access to both home-based peritoneal dialysis (PD) and home hemodialysis (HHD) treatment modalities, but it is unclear whether regional disparities in home dialysis (PD and HHD) were affected. We compared regional home dialysis use by White and non-White individuals over time. Retrospective cohort study of dialysis facilities offering home dialysis in 2006-2016 and of 1,098,579 patients with prevalent ESKD in 2006-2016. We compared hospital referral region (HRR) utilization rates of home dialysis between White and non-White patients over time using a generalized estimating equation model with a negative binomial distribution adjusting for regional characteristics. The mean number of facilities offering home dialysis operating in each HRR increased from 15.6 in 2006 to 22.1 in 2016. Observed mean HRR home dialysis rates increased overall, but White patients maintained greater home dialysis use than non-White patients: 19.7% in 2006 and 26.2% in 2016 among White patients vs 13.0% in 2006 and 17.8% in 2016 among non-White patients. In adjusted analysis, there was no evidence of changes in White/non-White disparities in home dialysis use over time (P = .84) or after the Medicare ESKD PPS in 2011 (incidence rate ratio, 0.97; 95% CI, 0.92-1.02; P = .29). Even after modest increases in dialysis facility availability and patient utilization after the implementation of the Medicare ESKD PPS in 2011, significant racial disparities in home dialysis remain.

Trends in Peritoneal Dialysis Use in the United States after Medicare Payment Reform.

Peritoneal dialysis (PD) for ESKD is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis (HD), but has historically been underused. We assessed the effect of the 2011 Medicare prospective payment system (PPS) for dialysis on PD initiation, modality switches, and stable PD use. Using US Renal Data System and Medicare data, we identified all United States patients with ESKD initiating dialysis before (2006-2010) and after (2011-2013) PPS implementation, and observed their modality for up to 2 years after dialysis initiation. Using logistic regression models, we examined the associations between PPS and early PD experience (any PD 1-90 days after initiation), late PD use (any PD 91-730 days after initiation), and modality switches (PD-to-HD or HD-to-PD 91-730 days after initiation). We adjusted for patient, dialysis facility, and regional characteristics. Overall, 619,126 patients with incident ESKD received dialysis at Medicare-certified facilities, 2006-2013. Observed early PD experience increased from 9.4% before PPS to 12.6% after PPS. Observed late PD use increased from 12.1% to 16.1%. In adjusted analyses, PPS was associated with increased early PD experience (odds ratio [OR], 1.51; 95% confidence interval [95% CI], 1.47 to 1.55; P<0.001) and late PD use (OR, 1.47; 95% CI, 1.45 to 1.50; P<0.001). In subgroup analyses, late PD use increased in part due to an increase in HD-to-PD switches among those without early PD experience (OR, 1.59; 95% CI, 1.52 to 1.66; P<0.001) and a decrease in PD-to-HD switches among those with early PD experience (OR, 0.92; 95% CI, 0.87 to 0.98; P=0.004). More patients started, stayed on, and switched to PD after dialysis payment reform. This occurred without a substantial increase in transfers to HD.

An unintended consequence of provider payment reform: The case of capitation grants in the National Health Insurance reform of Indonesia.

One of the most important components of the ambitious 2014 National Health Insurance reform in Indonesia is the implementation of prospective payment system known as capitation grants, paid monthly to the primary health providers based on the enrolment rate. This has ushered in additional financial resources for the health managers in resource allocations, especially in the hiring of manpower. Drawing data from the Indonesia Family Life Survey (1993-2015), this paper uses difference-in-differences method to evaluate the effects of the payment method reform on the allocation of human resources for health among the primary health providers. To our surprise, there was no statistically significant change in the total number of full-time staff among the capitated facilities after the reform. However, capitation grants caused an increase in the number of full-time equivalent and part-time equivalent contract staff, but a significant decline in the number of full-time permanent staff among the urban capitated facilities. It is likely that more contract health workers were hired at the expense of full-time permanent staff among the capitated facilities in the urban regions. This unintended consequence shed light on the need to develop nuanced and contextual understanding of payment reforms in developing countries.

Association of Medicare's Bundled Payment Reform With Changes in Use of Vitamin D Among Patients Receiving Maintenance Hemodialysis: An Interrupted Time-Series Analysis

Medicare's 2011 prospective payment system (PPS) was introduced to curb overuse of separately billable injectable drugs. After epoietin, intravenous (IV)vitamin D analogues are the biggest drugcost drivers in hemodialysis (HD) patients, but the associationbetween PPS introduction and vitamin D therapy has been scarcely investigated. Interrupted time-series analyses. Adult US HD patients represented in the US Renal Data System between 2008 and2013. PPS implementation. The cumulative dose of IV vitamin D analogues (paricalcitol equivalents) per patient per calendar quarter in prevalent HD patients. The average starting dose of IV vitamin D analogues and quarterly rates of new vitamin D use (initiations/100 person-months) in incident HD patients within 90 days of beginning HD therapy. Segmented linear regression models of the immediate change and slope change over time of vitamin D use after PPS implementation. Among 359,600 prevalent HD patients, IV vitamin D analogues accounted for 99% of the total use, and this trend was unchanged over time. PPS resulted in an immediate 7% decline in the average dose of IV vitamin D analogues (average baseline dose= 186.5 μg per quarter; immediate change=-13.5 μg [P < 0.001]; slope change= 0.43 per quarter [P = 0.3]) and in the starting dose of IVvitamin D analogues in incident HD patients (average baseline starting dose= 5.22 μg; immediate change=-0.40 μg [P<0.001]; slope change=-0.03 per quarter [P= 0.03]). The baseline rate of vitamin D therapy initiation among 99,970 incident HD patients was 44.9/100 person-months and decreased over time, even before PPS implementation (pre-PPS β=-0.46/100 person-months [P < 0.001]; slope change=-0.19/100 person-months [P=0.2]). PPS implementation was associated with an immediate change in initiation levels (by-4.5/100 person-months; P < 0.001). Incident HD patients were restricted to those 65 years or older. PPS implementation was associated with a 7% reduction in the average dose and starting dose of IV vitamin D analogues and a 10% reduction in the rate of vitamin D therapy initiation.

Total Red Blood Cell Transfusions for Chronic Hemodialysis Patients in a Single Center, 2009-2013

Background: Anemia management in chronic hemodialysis (HD) has been affected by the implementation of the prospective payment system (PPS) and changes in clinical guidelines. These factors could impact red blood cell (RBC) transfusion in HD patients. Our distinctive care system contains complete records for all RBC transfusions among our HD patients. Aims: To determine RBC transfusions in patients with prevalent chronic HD, site of administration (inpatient or outpatient), and ordering physician specialty for inpatients; compare pre- and post-PPS RBC transfusions; and compare RBC transfusions during changes in desired outpatient hemoglobin (Hb) range for patients with chronic HD. Methods: Retrospective analysis of medical and blood bank records for patients with prevalent chronic HD July 2009 through June 2013. Results: In total, 310-356 patients were studied. Mean (SD) units of RBCs per 100 patients per month for the study's 48 months were outpatient, 2.6 (1.5), and inpatient, 9.4 (4.6). Outpatient pre-PPS RBC units transfused were 2.1 (0.6) vs. post-PPS of 2.6 (1.5; p = 0.22, t test); for inpatients pre-PPS, 7.9 (4.5) RBC units per month vs. post-PPS, 11.5 (5.1; p = 0.11, t test). Inpatient RBC transfusions accounted for 75.2% (14.2%) of all RBC transfusions; 67.3% (16.3%) of inpatient transfusions were ordered by nonnephrologists. Changes in desired Hb range for outpatient HD patients did not lead to changes in RBC transfusions. Conclusions: No changes in RBC transfusions occurred among our patients with chronic HD with PPS implementation and in desired Hb range during the study period. Most transfusions were given in inpatient settings by nonnephrologists.

Effects of Epoetin Alfa Titration Practices, Implemented After Changes to Product Labeling, on Hemoglobin Levels, Transfusion Use, and Hospitalization Rates.

Little is known about epoetin alfa (EPO) dosing at dialysis centers after implementation of the US Medicare prospective payment system and revision of the EPO label in2011. Retrospective cohort study. Approximately 412,000 adult hemodialysis patients with Medicare Parts A and B as primary payer in 2009 to 2012 to describe EPO dosing and hemoglobin patterns; of these, about 70,000 patients clustered in about 1,300 dialysis facilities to evaluate facility-level EPO titration practices and patient-level outcomes in2012. Facility EPO titration practices when hemoglobin levels were<10 and >11g/dL (grouped treatment variable) determined from monthly EPO dosing and hemoglobin level patterns. Patient mean hemoglobin levels, red blood cell transfusion rates, and all-cause and cause-specific hospitalization rates using a facility-based analysis. Monthly EPO dose and hemoglobin level, red blood cell transfusion rates, and all-cause and cause-specific hospitalization rates. Monthly EPO doses declined across all hemoglobin levels, with the greatest decline in patients with hemoglobin levels< 10g/dL (July-October 2011). In 2012, nine distinct facility titration practices were identified. Across groups, mean hemoglobin levels differed slightly (10.5-10.8g/dL) but within-patient hemoglobin standard deviations were similar (∼0.68g/dL). Patients at facilities implementing greater dose reductions and smaller dose escalations had lower hemoglobin levels and higher transfusion rates. In contrast, patients at facilities that implemented greater dose escalations (and large or small dose reductions) had higher hemoglobin levels and lower transfusion rates. There were no clinically meaningful differences in all-cause or cause-specific hospitalization events across groups. Possibly incomplete claims data; excluded small facilities and those without consistent titration patterns; hemoglobin levels reported monthly; inferred facility practice from observed dosing. Following prospective payment system implementation and labeling revisions, EPO doses declined significantly. Under the new label, facility EPO titration practices were associated with mean hemoglobin levels (but not standard deviations) and transfusion use, but not hospitalization rates.

Anemia management practice patterns in small dialysis organizations following implementation of the prospective payment system.

The impact of the United States Prospective Payment System (PPS) "bundle payment system" on anemia management within small dialysis organizations (SDOs) was studied to evaluate the financia burden on SDOs. Facilities enrolled in the original study on SDOs were grouped into three hemoglobin (Hb) categories by subject-months: > 25% of subjectmonths with Hb < 10 g/dL (sub-10); > 25% of subject-months with Hb > 12 g/dL (super-12); remaining facilities (10 - 12 group). Subjectlevel data aggregated to facility level for Hb concentration, intravenous (IV) epoetin ± (EA) dose per administration, dose titration, and EA administration frequency during the baseline and follow-up periods were described. Baseline demographic characteristics were imbalanced between the sub-10 (n = 7) and super-12 facilities (n = 5). Mean (SD) Hb concentrations were similar for sub-10 (11.1 (3.0) g/dL) and super-12 (11.6 (2.2) g/dL) facilities during the baseline period, but differed during the follow-up period (10.4 (2.7) vs. 11.4 (2.3) g/dL). The median (Q1, Q3) EA IV dose per administration during follow-up was 3,726 (3,467, 3,961) and 5,712 (4,816, 7,324) units in the sub-10 and super-12 facilities, respectively. A small trend toward upward titration was seen. Results suggest a difference in anemia management between sub-10 and super-12 facilities during the first year of PPS implementation. Future analyses evaluating patterns of reimbursement and shifts in clinical practice guidelines are warranted globally.

Managing oral phosphate binder medication expenditures within the Medicare bundled end-stage renal disease prospective payment system: economic implications for large U.S. dialysis organizations.

From January 2016, payment for oral-only renal medications (including phosphate binders and cinacalcet) was expected to be included in the new Medicare bundled end-stage renal disease (ESRD) prospective payment system (PPS). The implementation of the ESRD PPS has generated concern within the nephrology community because of the potential for inadequate funding and the impact on patient quality of care. To estimate the potential economic impact of the new Medicare bundled ESRD PPS reimbursement from the perspective of a large dialysis organization in the United States. We developed an interactive budget impact model to evaluate the potential economic implications of Medicare payment changes to large dialysis organizations treating patients with ESRD who are receiving phosphate binders. In this analysis, we focused on the budget impact of the intended 2016 integration of oral renal drugs, specifically oral phosphate binders, into the PPS. We also utilized the model to explore the budgetary impact of a variety of potential shifts in phosphate binder market shares under the bundled PPS from 2013 to 2016. The base model predicts that phosphate binder costs will increase to $34.48 per dialysis session in 2016, with estimated U.S. total costs for phosphate binders of over $682 million. Based on these estimates, a projected Medicare PPS $33.44 reimbursement rate for coverage of all oral-only renal medications (i.e., phosphate binders and cinacalcet) would be insufficient to cover these costs. A potential renal drugs and services budget shortfall for large dialysis organizations of almost $346 million was projected. Our findings suggest that large dialysis organizations will be challenged to manage phosphate binder expenditures within the planned Medicare bundled rate structure. As a result, large dialysis organizations may have to make treatment choices in light of potential inadequate funding, which could have important implications for the quality of care for patients with ESRD.

The German Prospective Payment System (PPS) for Psychiatric and Psychosomatic Facilities: Does Reimbursement Remunerate the Quality of Treatment of Inpatients Suffering From Multiple Substance Use?

Introduction In the context of the 2009 Hospital Financing Reform Act (KHRG) in Germany the implementing of a Prospective Payment System (PPS) for psychiatric and psychosomatic facilities was determined. The PPS is based on per diem payments adjusted for diagnoses, patient characteristics and procedures and is controversially discussed. Objectives The psychiatric department of Klinikum Chemnitz gGmbH has been participating in the optional and budget-neutral phase of implementation of PPS since 2013. Aims Against the background of increasing number of inpatients with main diagnosis (MD) F19.-[ICD10], quality and reimbursement of the treatment of this patient group under PPS conditions were analyzed. Methods Patient groups with MD F19.-'With Utilization' and 'Without Utilization' of qualified detoxification treatment in 2013 were retrospectively compared by focusing on the criteria 'Quality '(service intensity, ratio of therapeutic services, ratio of discharges against medical advice, length of stay) and 'Reimbursement by PPS'(catalogue 2014). Service intensity and reimbursement by PPS were illustrated by valuation ratios in relation to patient group with MD F3.-(value 1). Results Utilization of qualified detoxification treatment was associated with higher service intensity, a higher ratio of therapeutic services and a lower ratio of discharge against medical advice while reimbursement by PPS was lower (fig.1). Discussion The high quality of qualified detoxification treatment is insufficiently reimbursed by PPS in 2014. This is among other reasons a consequence of the inbuilt payment degression relating to length of stay. Although the PPS cataloque in 2015 includes several improvements further discussion and research regarding PPS is required. Download : Download full-size image

Prospective Payment System Implementation and Earlier Inpatient Rehabilitation Admission

The prospective payment system (PPS) went into effect in October 2001. This study examines whether the average onset days torehabilitation has differed from the pre-PPS period to post-PPS.

Early Trends From the Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS)

Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011. Prospective observational cohort study of patients from a sample of 51 small dialysis organizations. 1,873 adult hemodialysis and peritoneal dialysis patients. Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions. Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis. Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients. Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature. In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.

Impact of Medicare Prospective Payment System on Acute Rehabilitation Outcomes of Patients With Spinal Cord Injury

Qu H, Shewchuk RM, Chen Y, Deutsch A. Impact of Medicare prospective payment system on acute rehabilitation outcomes of patients with spinal cord injury. Objective To examine the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on inpatient rehabilitation outcomes for patients with traumatic spinal cord injury (SCI). Design Retrospective study. Setting Twelve SCI Model Systems. Participants A sample of Medicare (n=296) and non-Medicare (n=3110) patients was selected from the National SCI Statistical Center Database from 1996 to 2006. Interventions Not applicable. Main Outcome Measures Motor FIM score change and length of stay (LOS). Results LOS decreased by about 5.8 days a year ( P<.001) for Medicare patients and about 1.3 days a year ( P=.031) for non-Medicare patients after PPS implementation. However, for both groups, FIM score gains were not significantly different in the pre-PPS and PPS periods. Conclusions Although significant decreases in LOS were observed for Medicare patients after IRF PPS implementation, Medicare patients' improvements in motor function did not decrease. Non-Medicare patients with SCI also experienced shortened stays after Medicare IRF PPS implementation, but had equivalent FIM score gains compared with their counterparts who received inpatient rehabilitation care before PPS implementation. IRF PPS implementation was associated with shorter stays, but was not associated with lower functional improvement.

Psychiatric Discharges in Community Hospitals With and Without Psychiatric Units: How Many and for Whom?

Psychiatric Discharges in Community Hospitals With and Without Psychiatric Units: How Many and for Whom?

Psychiatric Discharges in Community Hospitals With and Without Psychiatric Units: How Many and for Whom?

This study sought to describe the extent to which community hospitals, in a sample of states, are caring for patients with psychiatric disorders in medical-surgical beds (scatter beds) and to compare the characteristics of patients treated in scatter beds with those of patients treated in psychiatric units in community hospitals. Information on hospital discharges in 12 states for patients with a principal psychiatric diagnosis was gathered from the Healthcare Cost and Utilization Project State Inpatient Databases. Discharges of patients who were treated in community hospital psychiatric units (N=370,984) were compared with those of patients who were treated in scatter beds (N=26,969). Overall, only 6.8% of discharges were from scatter beds. The rate of total psychiatric discharges per 10,000 total state population ranged from a high of 62.3 in one study state to a low of 9.6 in another. The average rate of scatter bed discharges per 10,000 state population ranged from 1.6 to 5.8, whereas the average rate of psychiatric unit discharges ranged from 7.4 to 58.9. A comparison of discharges of patients treated in scatter beds with discharges of patients treated in psychiatric units indicated that patients in scatter beds were more likely to have somatic conditions and were half as likely to have an accompanying substance use disorder. Discharge codes indicated that almost 40% of patients from scatter beds had a diagnosis of schizophrenia, episodic mood disorder, or depression; about two-thirds were admitted from emergency rooms; and about one-fifth were transferred to another facility. More research is needed to determine the optimal supply of psychiatric unit beds across regions and whether and how scatter beds should be used to address the lack of psychiatric beds.

Trends in Inpatient Rehabilitation Stroke Outcomes Before and After Advent of the Prospective Payment System: A Systematic Review

The purpose of this systematic review was to examine quality care indicators for inpatient stroke rehabilitation, trends for length of stay (LOS), functional outcomes, and discharge destination. In order to examine the influence of the prospective payment system (PPS), which was instituted in 2002, particular attention was paid to the pre-PPS to post-PPS period. This is the first review of literature to examine the quality of stroke care provided in inpatient rehabilitation facilities in the United States. A search of Ovid Medline and Ovid Cumulative Index of Nursing and Allied Health databases was performed for articles published between 1990 and 2007. Search terms included treatment outcome, outcome assessment, activities of daily living, exercise, rehabilitation, cerebrovascular accident, LOS, and rehabilitation centers. Twelve articles met the criteria for review. A trend for shorter LOS was evident in the literature up until the time of implementation of PPS. An insufficient amount of literature was available to confirm whether this trend continued after the implantation of PPS. The most recent data indicated that average LOS in inpatient rehabilitation facilities for stroke was <20 days. Functional Independence Measure (FIM) discharge scores remained stable through the 1990s. After the implementation of PPS, discharge FIM scores may be decreasing, but revisions to the FIM tool may confound interpretation of post-PPS findings. Data for discharge to noninstitutional settings after stroke rehabilitation were inconclusive pre-PPS. There may be indications that discharges to institutional settings are increasing post-PPS. The impact of PPS on quality care indicators for inpatient stroke rehabilitation, trends for LOS, and trends for functional outcomes are insufficiently documented in the medical literature. Further research is needed to understand the influence of LOS on functional outcomes and discharge destination. More information is needed on post-PPS outcomes to substantiate the benefit of inpatient rehabilitation for individuals with stroke.

Poster 62: The Comparison of Rehabilitation Outcomes for Patients With Spinal Cord Injury Before and After Prospective Payment System Implementation

Poster 62: The Comparison of Rehabilitation Outcomes for Patients With Spinal Cord Injury Before and After Prospective Payment System Implementation

The Impact of the Inpatient Rehabilitation Facility Prospective Payment System on Stroke Program Outcomes

To examine the impact of the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS) on outcomes in a stroke rehabilitation program. An analysis was performed on a database including 945 stroke patients admitted to an inpatient stroke rehabilitation program 5 yrs before implementation of the IRF PPS and 3.5 yrs after implementation. Patients were classified with regard to stroke location (left vs. right), level of cognitive impairment, presence/absence of unilateral neglect, and level of depressive symptomatology. Functional status was evaluated at time of admission and discharge by functional independence measure (FIM). Other outcome measures included length of stay (LOS) and discharge destination. The impact of IRF PPS on LOS, progress in rehabilitation, and discharge destination was examined via univariate analyses of covariance and logistic regression. Patients admitted after implementation of the IRF PPS had shorter LOS but made less progress, had lower functional levels at discharge, and had higher rates of institutional discharge. Although associated with decreased LOS, implementation of the IRF PPS was associated with decreased functional gains, lower discharge FIM levels, and higher rates of institutional discharge. Cost savings associated with the PPS must be considered in light of these untoward outcomes.

The Effect of Medicare's Prospective Payment System on Patient Satisfaction

To examine the impact of Medicare's Prospective Payment System (PPS) on patient satisfaction at four inpatient rehabilitation hospitals. Prospective study using a satisfaction survey to examine the effects of Medicare's PPS for rehabilitation hospitals. Surveys were conducted at four affiliated rehabilitation hospitals in the Midwest. Patient characteristics varied only slightly pre- to post-PPS, and several characteristics were related to overall satisfaction, including motor functional gain, discharge to home, and respondent (patient or proxy). A 12-point increase on a 12-item motor function scale resulted in 1.13 greater odds (95% CI: 1.04, 1.24) of reporting excellent satisfaction. Patient respondents were 1.27 times more likely (95% CI: 1.07, 1.50) than proxies to report excellent satisfaction, and patients discharged home were 1.65 times more likely (95% CI: 1.31, 2.07) to report excellent satisfaction than patients discharged elsewhere. We found an increase in observed satisfaction from 60.3 to 63.4% (P < 0.05) after PPS implementation, despite a decrease in motor FIM gain. Patient characteristics such as motor FIM gain, discharge status, and respondent type were significantly associated, although only slightly, with patient satisfaction in inpatient rehabilitation. Percentage of excellent satisfaction improved at these four facilities after PPS implementation, despite declines in motor FIM gain. The improvement may be the result of numerous ongoing quality-improvement initiatives directed at improving patient satisfaction at these facilities.

The Early Impact of the Inpatient Rehabilitation Facility Prospective Payment System on Stroke Rehabilitation Case Mix, Practice Patterns, and Outcomes

DeJong G, Horn SD, Smout RJ, Ryser DK. The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes. Objective To determine the early effects of the inpatient rehabilitation facility (IRF) prospective payment system (PPS) on stroke rehabilitation case mix, practice patterns, and outcomes. Design Prospective observational cohort study. Setting Three IRFs in the United States. Participants Consecutively enrolled convenience sample of 539 stroke rehabilitation patients treated between 2001 and 2003 in 3 IRFs. Interventions Not applicable. Main Outcome Measures Length of stay (LOS), therapy utilization, FIM instrument gain, and discharge destination. Results The IRF-PPS had no material short-term effect on stroke rehabilitation case mix and LOS for the study facilities. Facilities shifted physical and occupational therapy resources from those in the most severe case-mix groups (CMGs) to those in the moderate CMGs. Those in the more severe CMGs also experienced a noticeable decline in FIM score gain over the course of the rehabilitation stay. Using multivariate analyses, the authors discerned no major role for the IRF-PPS in explaining pre- and post-PPS differences in utilization and outcome among study facilities. Conclusions For the 3 study facilities, IRF-PPS did not materially reshape stroke rehabilitation case mix, utilization, and outcome in the early stages of PPS implementation, apart from the shift in therapy resources from more severely involved stroke patients to moderately involved patients. The study’s findings are limited to 3 facilities, and a longer time horizon is needed to more fully determine the effects of the IRF-PPS.