Database For Rehab Outcomes Stored At UB Could Set Standard For Medicare Reimbursements

BUFFALO, N.Y. -- A small suite of offices in a nondescript building on the University at Buffalo South (Main Street) Campus holds 4 million records comprising the largest database of medical rehabilitation treatment outcomes in the world.

Called the Uniform Data System for Medical Rehabilitation (UDSMR), this mother lode of information came to reside in this place because of a whimsical-sounding item called the "FIMTM instrument." However, there is nothing whimsical about its purpose.

The FIM, or Functional Independence Measure, is an assessment instrument developed at UB to quantify the ability of patients to care for themselves when they enter rehabilitation treatment and to chart their progress -- or lack of it -- until discharge into the community or to another facility.

Fifteen years after faculty members in the UB Department of Rehabilitation Medicine created the FIM instrument, they now are involved with the federal Health Care Financing Administration (HCFA) in developing an instrument to be used by rehabilitation hospitals and other rehabilitation units as the basis for Medicare prospective payment.

"HCFA has come to realize the importance of functional status as the common denominator among rehabilitation patients, and how improvements in functional status as the result of rehabilitation intervention could serve as a measure of the success of that hospital stay," stated Carl Granger, M.D., professor and chair of the UB Department of Rehabilitation Medicine and one of the developers of the FIM instrument.

The effort to develop a standard for measuring rehabilitation's effectiveness was spurred by Medicare's move in 1983 to use diagnosis-related groups (DRGs) as the basis for reimbursement for acute care hospitals, Granger said.

Since patients admitted for rehabilitation are treated not only by diagnosis, but also by level of disability, the DRG reimbursement system was not appropriate. Lacking a standard comparable to the acute-care hospital, rehabilitation facilities have been reimbursed for care, until now, based on an allowance per case discharged, regardless of the time and resources expended.

Realizing the need to get in step with the rest of the health-care industry, the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation formed a national task force to press for development of a standard for documenting the level of disability and outcomes of medical rehabilitation.

UB received a three-year grant in 1984 from the National Institute for Disability and Rehabilitation Research to develop such a standard. The UDSMR, the FIM instrument and UDSMR's data-management service are the result. Rehabilitation facilities began using the data service in 1987.

The FIM instrument and UDSMR were embraced by the industry with an enthusiasm that surprised even its creators, Granger said.

More than 4 million patients in 1,400 facilities covering all 50 states and the District of Columbia have been assessed since its introduction. The Veterans Affairs Medical System subscribes to the FIM instrument and UDSMR. The measurement instrument also has been translated into five languages and is used in Australia, Canada, Hong Kong, Japan, Finland and Sweden.

The FIM instrument is an easy-to-use assessment that allows trained personnel to assign a numerical value to a patient's ability to function, based on performance of 18 physical and mental categories that represent a typical daily routine. By assessing patients throughout their treatment and when they are discharged, a facility can follow their progress, chart their outcomes and compare the patient's progress to the cost of treatment.

UDSMR's 1,400 subscribers in the United States and Canada -- including 80 percent of current acute rehabilitation facilities -- submit their FIM data to UB and receive quarterly reports. The reports include a confidential comparison of the subscriber's outcomes with others in their region and the nation. UB maintains the database and has permission to use the data for scientific research.

The FIM instrument is not the only tool available for assessing rehabilitation treatment and outcomes, but it provides the basis for a common language that has been accepted by rehabilitation clinicians around the world, said Richard Linn, associate director of UDSMR and assistant professor of rehabilitation medicine and psychiatry.

A majority of acute rehabilitation hospitals and rehabilitation units in the United States have adopted it, Linn said, because it is easy to use and reliable: A patient's score at discharge has been shown to be an accurate indicator of how much care the patient will need upon return to the home.

"This allows us to tell the family what their care needs will be for any type of impairment, which makes the FIM SystemSM very practical," he said.

Facilities feel that they can rely upon the accuracy of the data, Linn said, because of UDSMR'S strong emphasis on training and credentialing, and because of UDSMR's non-profit status and its location on a university campus.

In developing the payment system for rehabilitation, HCFA looked to the Minimum Data Set (MDS), an instrument that was developed for payment of nursing-home services. The resulting instrument, the MDS-Post Acute Care (MDS-PAC), currently is under refinement and may include elements of the FIM instrument. According to MedPAC, the Medicare Payment Advisory Commission, HCFA and the rehabilitation community have long-standing disagreements over the extent to which various iterations of the MDS-PAC have incorporated the FIM instrument.

Granger said that the new instrument would be compatible enough with the FIM instrument to allow comparison between new data and "legacy" data accumulated for nearly two decades.

"UDSMR, regardless of the underlying instrument, will continue to serve the rehabilitation field as a provider of outcomes and national benchmarks," he stated.