New Medicare Rule Forces Cancer, Heart, and Lung Patients Into Nursing Homes

Valerie A. Jones, MD


The Centers for Medicare and Medicaid Services (CMS) has recently published a new set of reimbursement criteria for acute inpatient rehabilitation facilities (IRF).[1] Commonly referred to as the "75% rule," IRFs must prove that 75% of their patients have 1 of only 13 diagnoses. Otherwise, the facility risks losing all reimbursement from Medicare, for all hospital admissions to the IRF in that fiscal year.

The CMS estimates that fewer than 13% of IRFs would qualify for Medicare reimbursement given the current patient populations that they serve.[2] Cancer, cardiac, and pulmonary patients, for example, are excluded from the 13 possible diagnoses that are eligible for acute rehabilitation. Medicare patients who have undergone lifesaving surgeries with innovative technologies, such as left ventricular assist devices, chemotherapy, or lung transplants, will not have access to intensive rehab care, unless they pay out of pocket. Because most will not be able to afford this, they will be forced to attempt recovery in a subacute facility, also known as a nursing home.

Nursing homes are neither equipped nor staffed to handle the medical and physical needs of acute patients in the early stages of their recovery. Therefore, it is likely that large numbers of patients will be sent to nursing homes by default because they do not meet the criteria for inpatient rehabilitation and they are too ill to return home safely. These patients will likely suffer a prolonged and slower recovery, as well as fall victim to the risks associated with having acute medical needs in a facility ill-prepared to handle them. The reality is that patients recovering from cancer, cardiac surgery, or pulmonary deconditioning may have higher morbidities and mortalities because of the 75% rule.

Not only is Medicare's rule dangerous for a large number of the population of which they serve, but it sets a bizarre precedent; an entire medical specialty, namely, physical medicine and rehabilitation, is being restricted to treating, nearly exclusively, 13 diagnoses in the inpatient setting. What if a neurologist were told that 75% of his or her patients had to have 1 of 13 neurologic conditions, or else there would be no reimbursement for services rendered to any patients that he or she treated? Or how would an internist respond to an insurance company that would only reimburse for heart attacks, but not pneumonias, despite the evidence that both diseases benefit from treatment?

There have been numerous research studies confirming the utility of acute rehabilitation for patients outside the 13 diagnoses proposed by CMS. For example, the clinical benefits of cardiac rehabilitation have been well documented. They include decreased mortality, improved quality of life, and lower costs because of lower rehospitalization rates.[3] Inpatient pulmonary rehabilitation stays brief as 10 days have been shown to improve exercise tolerance and dyspnea.[4] Inpatient rehabilitation can improve both motor and cognitive function in patients with disability resulting from cancer or its treatment.[5]

Because only 13% of IRFs are treating the patient population suggested by the CMS and the other 87% will have only 3 years to become "compliant," there is going to be aggressive competition for patients who have one of the 13 diagnoses. IRFs may be tempted to admit patients with those diagnoses, but who would otherwise not truly require inpatient rehabilitation, in order to meet the 75% quota. Meanwhile, patients who would clearly benefit from an acute IRF stay may be passed over, for fear that the quota would be skewed and all Medicare funding revoked for the year. These legitimate patients will therefore end up in nursing homes, with extended stays and increased risk of disease and death. In the end, it is possible that the 75% rule will prove to be one of the most financially expensive, patient-discriminatory decisions made by a healthcare agency in the past decade.

Admission to an IRF should be based on individual patient functional status and his or her predicted benefit from an acute inpatient stay, rather than diagnosis alone. Rehabilitation medicine is unique in that it already has numerous functional assessment tools in regular use for patient evaluation and monitoring of progress.[6] Any number of these assessment tools could provide a sensible predictor of individual patient benefit from acute inpatient rehabilitation. For example, a patient who had been able to ambulate greater than 10 blocks without an assistive device prior to hospital admission for aggressive chemotherapy, but currently has unsteady gait and decreased endurance due to the drugs and a prolonged hospital stay, would be appropriate for admission to an IRF. On the other hand, a patient who had an acute stroke (one of the 13 diagnoses acceptable for automatic IRF admission) but had rapidly recovered the ability to walk without difficulty would not benefit from an acute rehabilitation stay.

The 75% rule is a very blunt instrument, and a poor attempt at reducing inpatient rehabilitation costs. It is likely to promote dishonest charting. (For example, a patient whose admission diagnosis is not one of the 13 listed in the 75% rule might have a secondary diagnosis that would qualify. That patient's diagnosis code could be changed to allow him or her access to an IRF). The rule is also likely to make it extremely difficult for certain patients with legitimate functional deficits to receive access to acute rehabilitative care. And finally, as previously argued, the rule will result in increased morbidity and mortality among patients who will be forced to recover in a subacute setting. This Medicare rule, above all others, was made to be broken.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.