Medicare PPS May Significantly Decrease Funding for Individuals with Severe Traumatic Brain Injury
Categories: Costs and Insurance
What affect will the Medicare Prospective Payment System for reimbursement have on inpatient rehabilitation for individuals with traumatic brain injury?
Past Studies Medicare uses a Prospective Payment System (PPS) that is intended to transfer the financial risk to the healthcare provider, instead of the payer. This is accomplished by paying
Inpatient rehabilitation services have their own form of PPS called Case-mix groups (CMGs). Case-mix groups are designed to forecast the cost of care for each individual that enters inpatient rehabilitation. CMGs are determined by an individual’s functional status at the time of admission to rehabilitation. “Functional status” refers to how independently an individual can perform activities needed for daily living. “Activities of daily living” are the very basic self-care activities that individuals perform to take care of themselves during a typical day. Examples include toileting, bathing, eating, and dressing. Other examples are thinking skills. They include the ability to remember things or figure things out, and communication skills. Individuals with traumatic brain injury can experience difficulty performing activities of daily living because brain injuries can affect the way they think, act, feel, and move their bodies.
Concerns have been raised that the PPS system would not pay for all of the services needed by individuals with severe trauma. In particular, individuals with severe traumatic brain injuries are some of the most costly patients in inpatient rehabilitation. Poor payment could possibly reduce the number of individuals with the
This study evaluated the
Who May Be Affected By These Findings
Individuals with traumatic brain injury and their loved ones, health care providers, insurers, advocates, and researchers.
The researchers state that although only a small amount of individuals with traumatic brain injury are funded by Medicare, these results are important because other payers are likely to follow the PPS example.
It appears that the PPS may significantly decrease funding for individuals with severe traumatic brain injury. The researchers speculate that inpatient rehabilitation centers may reduce the time an individual spends in their facility so that they do not lose money.
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Find This Study
Hoffman, J.M., Doctor, J.N., Chan, L., Whyte, J., Jha, A., & Dikmen, S. (2003).