The impact of the inpatient rehabilitation facility prospective payment system on stroke program outcomes

Objective: To examine the impact of the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS) on outcomes in a stroke rehabilitation program. Design: An analysis was performed on a database including 945 stroke patients admitted to an inpatient stroke rehabilitation program 5 yrs before implementation of the IRF PPS and 3.5 yrs, after implementation. Patients' were classified with regard to stroke location (left vs. right), level of cognitive impairment, presence/absence of unilateral neglect, and level of depressive symptomatology. Functional status was evaluated at time of admission and discharge by functional independence measure (FIM). Other outcome measures included length of stay (LOS) and discharge destination. The impact of IRF PPS on LOS, progress in rehabilitation, and discharge destination was examined via univariate analyses of covariance and logistic regression. Results: Patients admitted after implementation of the IRF PPS had shorter LOS but made less progress, had lower functional levels at discharge, and had higher rates of institutional discharge. Conclusions: Although associated with decreased LOS, implementation of the IRF PPS was associated with decreased functional gains, lower discharge FIM levels, and higher rates of institutional discharge. Cost savings associated with the PPS must be considered in light of these untoward outcomes.