Wilson Says New Federal Rule Will Hurt New Mexico Seniors

Press Release

Wilson Says New Federal Rule Will Hurt New Mexico Seniors

Congresswoman Heather Wilson is supporting federal legislation to preserve access to inpatient rehabilitation services for New Mexico patients, particularly seniors. Wilson is opposing an Administration measure intended to reduce costs by requiring 75% of in-patient rehabilitation services be for specific diagnoses -- the so-called 75% rule.

The Administration rule increases significantly a patient quota that rules how rehabilitation hospitals are reimbursed for Medicare patients. Health professionals say the new rule makes it harder to provide appropriate and medically-necessary care and will force hospitals to turn patients away.

Wilson says that even though the details of the rule are technical, its effect on New Mexicans is clear: New Mexicans might be denied critical medical services unless the Administration's new "75%" rule is scaled back.

That's why she has decided to co-sponsor the Preserving Patient Access to Inpatient Rehabilitation Hospitals Act (H.R. 1459). The bill prevents CMS from implementing the ‘75% Rule', and instead sets a ‘60% Rule' that health care providers say is more realistic and offers the flexibility necessary to provide physician-driven care.

"Arbitrary quotas don't make sense," says Wilson. "This quota could reduce access to rehabilitation services for seniors in New Mexico, and I think that's wrong."

"The 75 percent rule limits patient access to inpatient rehabilitation by using an arbitrary quota system rather than physician-driven medical determinations," said Ulrike Berzau, CEO of Lovelace Rehabilitation Hospital. "We are grateful Rep. Heather Wilson has decided to champion this very important issue for New Mexico's rehabilitation patients."

"It's obvious that the 75 percent rule creates a barrier for patients in need of inpatient rehab and pushes them to nursing homes, which is unfortunate because there is a big difference between a rehab hospital and a nursing home. Extensive research has shown that patients who are treated in rehab hospitals have far superior outcomes in a much shorter period of time. We appreciate Congresswoman Wilson's continued support of our efforts to fix the problems created by the 75 percent rule," said Sylvia Kelly, Chief Executive Officer at HealthSouth Rehabilitation Hospital in Albuquerque.

Wilson explains that a person admitted to a rehabilitation facility for care prescribed by his or her doctor might be turned away if admitting that patient skews the facility's admittance numbers and threatens their Medicare funding.

"When a New Mexico senior is being evaluated by doctors, I want treatment decisions to be made based on that senior's medical condition and needs. I think it's wrong to hand over the decision solely to a formula."

The Administration, through the Center for Medicare and Medicaid Services (CMS), is phasing in the so-called "75% rule" that determines how rehabilitation facilities are reimbursed by Medicare. It forces them to treat a certain percentage of patients for specific ailments, which arbitrarily limits the number of patents who can be treated for other ailments.

Under the new rule, in order to qualify as an inpatient rehabilitation facility under Medicare—and hence get paid for treating seniors—a specific percentage of patients must be diagnosed with just 13 conditions. Without the legislation Wilson is supporting, the threshold will increase incrementally until it reaches 75%. On July 1, it increased to 65% and will jump to 75% in July 2008.

"This legislation will protect access to intensive rehabilitative care for seniors following a stroke, brain injury, hip replacement surgery, and many other conditions," says Wilson. "A patient's care is more than their diagnosis. Their rehabilitative potential is key to returning a person to a productive life."

Due to the 75 Percent Rule, many appropriate patients previously served in rehabilitation hospitals and units are being denied access to clinically intense and promising inpatient rehabilitation services that are both medically necessary and would lead to superior patient outcomes in a shorter period of time than other settings might accomplish.

The Centers for Medicare & Medicaid Services (CMS) estimated that during the first two years of the 75 Percent Rule's phase-in, only 7,000 fewer patients would be treated. However, the American Hospital Association estimates this rule has already denied 88,000 patients access to needed care.

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