Patients Feel the Pressure of PPS Data Show Impact on Inpatient Rehabilitation Settings On the Pulse
On the Pulse  |   May 01, 2003
Patients Feel the Pressure of PPS
Author Notes
  • Tobi Frymark, is ASHA’s treatment outcomes manager. Contact her at
    Tobi Frymark, is ASHA’s treatment outcomes manager. Contact her at×
Article Information
Speech, Voice & Prosodic Disorders / Swallowing, Dysphagia & Feeding Disorders / Healthcare Settings / Research Issues, Methods & Evidence-Based Practice / Practice Management / On the Pulse
On the Pulse   |   May 01, 2003
Patients Feel the Pressure of PPS
The ASHA Leader, May 2003, Vol. 8, 1-10. doi:10.1044/leader.OTP1.08092003.1
The ASHA Leader, May 2003, Vol. 8, 1-10. doi:10.1044/leader.OTP1.08092003.1
It’s been approximately one year since inpatient rehabilitation settings began phasing in the Medicare Prospective Payment System (PPS). For many freestanding rehabilitation hospitals and hospital rehab units, this has meant doing away with the previously used, cost-related reimbursement method and initiating the predetermined, flat-rate-per-discharge method federally mandated by the Centers for Medicare and Medicaid Services as part of the Balanced Budget Act of 1997. Under this new capitated system, Medicare payment for rehabilitation services is now primarily based on the patient’s functional status and impairment level using the widely known Functional Independence Measures (FIM).
In the past, ASHA has voiced significant concerns not only regarding the use of the FIM as the sole outcomes measurement tool in determining resource allocation to patients with cognitive, communication, and swallowing disorders, but—more fundamentally—regarding the underlying effects of PPS on speech-language pathology services.
Historically, the implementation of PPS within other health care settings has led to dramatic changes for many of our colleagues. Clinicians working in skilled nursing and acute care facilities have reported a decrease in speech and language referrals, staffing cutbacks, and greater productivity demands with the onset of PPS. In addition, speech-language pathologists have indicated that these trends have adversely affected the quality of patient care.
Unfortunately, because no hard data existed at the time PPS was implemented for these settings, it was virtually impossible to benchmark fully the sweeping changes in utilization and patient outcomes, thereby leaving SLPs without the necessary ammunition to face these challenges head on.
Assessing the Impact
That is, until now. In 2002, ASHA launched a special data collection project to evaluate the impact of the Inpatient Rehabilitation Facility Prospective Payment System (IRFPPS) on speech-language pathology services using data from the National Outcomes Measurement System (NOMS). Through NOMS, ASHA was able to determine to what extent, if any, patient outcomes were compromised under this new reimbursement system by comparing post-PPS with pre-PPS data from Medicare patients.
To do this, 96 sites collected data on a total of 2,631 patients. Each of the 96 sites actively participated in NOMS prior to initiating PPS in their rehab facilities and provided services to Medicare patients. In addition, each site included data on non-Medicare, as well as Medicare, patients in their rehabs and other treatment settings. The collection of data on these diverse patient populations allowed ASHA to determine whether changes seen in outcomes in post-PPS Medicare inpatient rehab patients were specific to that patient group, or part of a broader change affecting other payers or treatment settings.
To fully assess the impact of IRFPPS, SLPs reported their standard NOMS data, which included the Functional Communication Measure (FCM) scores, along with information about patient demographics, diagnosis, service delivery and amount, and intensity and frequency of services. Clinicians also reported three additional pieces of information, which included FIM scores at admission, FIM scores at discharge, and the patient’s destination upon discharge.
Patient Outcomes Compromised
Not surprisingly, the results reveal what clinicians have long suspected. Patients receiving speech-language pathology services at the inpatient rehabilitation level indeed have been compromised under IRFPPS, most specifically in the area of patient outcomes. Study findings highlight specific differences in speech-language pathology service delivery as a result of PPS and its direct impact on communication and swallowing progress.
Primarily, NOMS data show a major decline in length of stay under PPS. As shown in Figure 1, after the onset of IRFPPS, far fewer patients received services for 30 or more days and far more received services for fewer than 20 days. On average, lengths of stay were reduced by roughly seven days.
It should be noted that, despite the abbreviated length of stay, there seemed to be no significant change in the amount of speech and language treatment patients received. Patients continued to receive approximately 10 hours of speech-language pathology treatment compared to 11 hours prior to PPS. What did change, however, was the intensity and frequency of speech-language pathology services. The majority of patients (89%) shifted from five or fewer speech and language sessions per week to more than five sessions per week post-PPS (77%). This meant that clinicians compensated for the decreased length of stay by providing more treatment sessions in a condensed time period.
What the Data Reveal
At first glance, these clinical modifications appear to effectively offset any changes in patient outcomes for inpatient rehabilitation facilities. Figure 2 illustrates that communication and swallowing progress essentially remains unchanged under PPS.
A closer look at the data show that this isn’t really the case. Although patients do make progress under PPS, there is an overwhelming difference in the amount of functional progress they make. Figure 3 illustrates a significant decline in patients achieving multiple levels of FCM progress post-PPS, particularly in the areas of swallowing, motor speech, and memory.
As a result of PPS, patients with communication and swallowing disorders leave this treatment setting at a less functional level than they would otherwise and possibly require more intensive speech-language pathology services at a subsequent level of care. NOMS data reveal that many more patients are being discharged to home or to a skilled nursing facility with further intervention required.
The findings from this data collection project only begin to detail the changes in speech-language pathology services and outcomes resulting from PPS implementation. As clinicians continue to gain more experience with PPS and the use of outcomes data, they will be able to mount effective strategies for streamlining service delivery costs without sacrificing the quality of patient care.
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May 2003
Volume 8, Issue 9