Just days before the end of 2007, President Bush signed into law the Medicare, Medicaid and State Children’s Health Insurance Program (SCHIP) Extension Act, which, among many other health care benefits, will help maintain patients’ access to the higher level of rehabilitative care and services provided by inpatient rehabilitation hospitals and hospital-based rehabilitation units.

Doctors are in the best position to prescribe inpatient rehabilitation for seniors, people with disabilities and others who need them following illness or injury. However, under a little-known Medicare regulation, patients’ ability to access care and services provided by inpatient rehabilitation hospitals and units often is determined by their medical diagnosis, and not necessarily their doctor’s, pursuant to their medical and rehabilitative care needs.

The regulation, historically known as the “75% Rule,” requires hospitals and units to treat a minimum percentage (75 percent) of patients whose medical condition or diagnosis falls within a specific list of 13 categories, such as stroke, spinal injury, Parkinson’s disease, hip fracture or joint replacement. This quota-based policy was substantially revised in 2004 to reduce the types of diagnoses – i.e., patients – who could satisfy the Rule and thus receive the specialized care offered at inpatient rehabilitation hospitals.

How the new law helps patients

The Medicare, Medicaid and SCHIP Extension Act provides more control to physicians in determining where their patients receive rehabilitative care. The new law permanently maintains the inpatient rehabilitation hospital compliance threshold limit at 60 percent (where it had been for the previous two years), thereby establishing a “60% Rule,” and allows patients’ “comorbidities” – or secondary medical conditions – to continue serving as a basis for access to inpatient rehabilitative care.

Permanently maintaining the Rule’s threshold percentage at 60 percent is significant for patients, as not doing so would have meant the threshold would have automatically escalated to 65 percent and ultimately 75 percent. This would have imposed increasingly tight restrictions on physicians and their ability to prescribe inpatient rehabilitation care, which would have substantially reduced access to care for many patients.

The new law’s treatment of a patient’s comorbidities is very important. Under the prior law, a patient’s comorbid medical condition or diagnosis could be deemed compliant with the Rule, as long as it was one of the Rule’s 13 and significantly contributed to the patient’s overall need for inpatient rehabilitation.

Because access to the care and services offered by inpatient rehabilitation hospitals and units will not be further eroded by this quota-based policy, patients with substantial rehabilitation care needs will have an opportunity to have those needs met in a rehabilitation hospital, where a team approach offers a rigorous rehabilitation regimen and higher level of care – including greater physician involvement and therapy time – than nursing homes or other less intensive care settings.

Highlights of law regarding Inpatient Rehabilitation Hospitals:

• Whether a patient receives rehabilitation care in a rehabilitation hospital will be determined more by the physician, as well as the patient’s medical and rehabilitative care needs, and less by diagnosis alone.
• Inpatient rehabilitation hospitals and units will not be forced to reduce the number of beds or decrease staff, thus allowing them to focus on providing high quality care to patients.
• The law helps promote quality of life for patients who have serious rehabilitation needs by preserving access to safe and specialized care in rehabilitation hospitals and units.