Irma G. Fiedler

Economics of managed care in spinal cord injury

OBJECTIVE To determine and describe trends in economic variables related to the care of individuals with spinal cord injury (SCI) and significant changes in these trends coincident with major developments in medical care cost control. DATA SOURCES Data from the National Spinal Cord Injury Statistical Center (NSCISC) database were used to review the economic trends in SCI management from 1973 to 1998 and their relation to managed care and other health care cost-containment measures. A panel of SCI health care specialists was interviewed to determine the appropriate data variables to be reviewed. The Shepherd Center Care Health Management Program, Atlanta, GA, is presented as an example of a fiscally successful managed care program for patients with SCI. DATA EXTRACTION Data from the NSCISC database for the years studied were extracted and converted to a form suitable for analysis by means of the statistical software SAS. DATA SYNTHESIS Statistical techniques included multiple regression analysis, logistic regression analysis, and model selection methods. CONCLUSIONS Trends in economic variables, in the care of individuals with SCI show changes coincident with the introduction of Diagnostic Related Groups (DRGs) and managed care as models for provider reimbursement. Significant changes occurred in acute care charges, rehabilitation charges, length of stay, rehospitalization 1 year postinjury, time from injury to admission to a Model System, and discharges to a nursing home.

Perceived Barriers to Employment in Individuals with Spinal Cord Injury

This study assessed the factors influencing employment for individuals with spinal cord injury (SCI). Employment status and the perceived barriers to employment were assessed in a home interview with 97 community-based individuals, mean time 6.6 years postinjury. More than half of the unemployed individuals with SCI, with stated motivation to work, remain unemployed. The perception of barriers and of factors helpful to employment differs significantly between employed and unemployed individuals. Lack of transportation was ranked as the number one barrier among the unemployed. Lack of Social Security benefits was ranked as the number two perceived barrier among the employed and seventh in the unemployed.

Ethical issues in rehabilitation: conceptualizing the next generation of challenges.

Kuczewski M, Fiedler I: Ethical issues in rehabilitation: conceptualizing the next generation of challenges. Am J Phys Med Rehabil 2001;80:848–851.

Perceived Versus Actual Physical Accessibility of Substance Abuse Treatment Facilities

This study addressed the perception of managers of substance abuse treatment facilities regarding physical accessibility for persons with spinal cord injury. Thirty of 32 facilities that were surveyed (94%) reported being wheelchair accessible in a telephone interview. An on-site survey of 15 of these programs revealed differences between reported and actual accessibility, with variations in the degree to which they actually met Americans with Disabilities Act accessibility guidelines. Thirteen of the 15 facilities (87%) had some physically inaccessible elements in their physical plant and programs. Continued education is essential to ensure that treatment facilities understand the access needs of persons with disability.

Integration of physical medicine and rehabilitation into the undergraduate medical curriculum. The Undergraduate Education Committee of the Association of Academic Physiatrists Workgroup.

The incorporation of PM&R into the medical student curriculum thus provides benefits at multiple levels: to patients, to medical students, and to practitioners already in the field. The knowledge about PM&R gained by the medical student is spread to disciplines outside of PM&R through the learning of principles and specific factual data that can be applicable for practitioners caring for a variety of patients. It is the position of this organization that each academic department work to integrate education in PM&R into the medical school curriculum.

The challenge of teaching rehabilitative care in medical school

Rehabilitative care has gained importance because the population is aging, and improved acute and chronic medical care saves and prolongs lives but leaves some patients with temporary or permanent physical impairments. However, despite its importance, the teaching and learning of rehabilitative care in medical school lag behind medical education relating to acute and chronic care. The authors analyze the broad scope of rehabilitative care and the need to include it in the medical school curriculum. They also discuss advantages for students and their patients of learning rehabilitative care in the undergraduate curriculum and suggest methods to improve teaching it.

Continuity of care. A teaching model.

Recent changes in health care mandate innovative approaches to teaching. Rehabilitation as part of the continuum of disability motivated the “continuity of care model.” This model permits the presentation of rehabilitation in its global sense: from onset of injury through re-integration into the community. This report describes a curriculum for physical medicine and rehabilitation residents that comprises a three-phase approach to rehabilitation: acute care, inpatient rehabilitation and community re-entry. The curriculum is adaptable for medical students. A secondary benefit of the project for the resident is a better understanding of relevant cost benefit/cost effective concepts in the delivery of quality services. The close interaction of residents with community agencies permits these agencies to gain a better understanding of the medical needs of disabled people

Specificity of ICD-9-CM coding practices for stroke rehabilitation

Designed for acute care classification, the 9th version of the International Classification of Disease, Clinical Modification (ICD-9-CM) is also used to describe the principal diagnosis in medical rehabilitation. ICD-9-CM (ICD-9) coding practices for all stroke cases found in two nationally representative databases were examined (sample sizes over 17,000 and over 2,000). Of the more than 100 codes selected, four were indicated for 67% and 72% of stroke cases in the two data sets, respectively. Codes 436 and 438 distinguish acute from late stroke effects; whereas code 434.9 identifies stroke, but not its duration. The most frequently used code in the larger database, 342.9, refers to the manifestation of hemiplegia rather than to diagnosis, and thus is not specific to stroke. Other less frequently selected ICD-9 codes are more specific to the underlying pathophysiology (e.g., thrombosis, embolus or hemorrhage). Results emphasize the need for more precise selection of etiologic ICD-9 codes for stroke rehabilitation so that they describe specific pathology.

Poster 3: Reasons for Medical Necessity Based Denials of Coverage by Medicare for Inpatient Rehabilitation Hospital and Unit (IRH/U) Admissions: Expert Assessment of the Clinical Reasons Cited and Their Appropriateness

Disclosures: B. M. Gans, Kessler Institute for Rehabilitation, Employment; Select Medical Corporation, Employment; Five Star Quality Care, Inc, Consulting fees or other remuneration; Hospitality Properties Trust, Consulting fees or other remuneration; Chair, AMRPA Board of Directors, Non-remunerative positions of influence President Foundation for PM&R, Non-remunerative positions of influence; Director, ThinkFirst Foundation, Non-remunerative positions of influence Director, APEC, Non-remunerative positions of influence Professor, UMDNJ-NJMS, Other. Objective: To examine a sample of IRH/U admissions for which coverage was retroactively denied by Medicare to determine what factors contributed to the denials, and to compare the determinations with professional standards and expert medical opinion. Design: Reviews of medical records by expert physiatrists in a group setting. Setting: 24 medical records from a variety of IRH/U in the United States. Each case was denied for coverage both by a Fiscal Intermediary (FI) and also on appeal to the Qualified Independent Contractor (QIC). All cases were then appealed to an ALJ. Participants: Eight expert physiatrists highly experienced as medical directors of inpatient rehabilitation hospitals or units. Interventions: Not applicable. Main Outcome Measures: Survey score sheets using primarily dichotomous response options. For each item of each case, the presence of a specific factor being cited as a reason for denial was determined if at least 6 of the 8 independent reviewers identified it as so. Similarly, concurrence or disagreement with the judgment of the Medicare Contractor was determined. Results: Of the 24 cases reviewed, 14 claims were paid because of the judgments of the ALJ, 2 were paid in part, and 8 continued to be denied for coverage. The majority of cases involved patients with orthopedic diagnoses (87%). Need for either close medical supervision or intense therapy services were the 2 reasons most commonly cited by the FI, QIC and ALJ for denial of coverage. Diagnosis was not explicitly cited as a reason for denial. The experts achieved consensus in 21 of 24 cases that the decisions of the FIs and QICs to deny payment did not meet the Academy’s Standards. Experts disagreed with the ALJs in 5 of 8 cases ruled unfavorably. Conclusions: This study showed how varied the expert opinions of experienced physiatrists may be regarding the application of expert judgment or the Academy’s Standards. It also showed how inconsistent the determinations by FIs, QICs, or ALJs may be with either expert judgment or the Academy’s standards. Other means of achieving resolution to the ongoing conflicts between physicians, Medicare contractors and IRH/U will need to be developed.