1. Rehabilitation and Regenerative Medicine PM&R in Subacute Rehabilitation: Attending Physician or Consultant? Joel Stein, MD Simon Baruch Professor and Chair

2. Rehabilitation and Regenerative Medicine Disclosures None specifically related to this presentation Research support from Nexstim, Tibion, Myomo, Tyromotion Member of Scientific Advisory Board - Myomo, Inc. (uncompensated)

3. Rehabilitation and Regenerative Medicine PM&R Physician Role in IRF CMS: “Require physician supervision by a rehabilitation physician, with face-to-face visits at least 3 days per week to assess the patient both medically and functionally and to modify the course of treatment as needed” Daily physician visits 5-7 days/week are typical

4. Rehabilitation and Regenerative Medicine PM&R Residency Requirements (ACGME) Residents must have direct and complete responsibility for the rehabilitative management of patients on the inpatient PM&R service. Each resident responsible for a minimum of 6 – 14 inpatients (average of 8). Residents should have inpatient rounds to evaluate patients with faculty members at least five times per week.

5. Rehabilitation and Regenerative Medicine SNF regulations Initial MD visit within 30 days of admission, and at least once every 30 days for the first 90 days after admission. Physician orders needed for medications on admission

6. Rehabilitation and Regenerative Medicine Financial Aspects – E&M Medicare: SNF 99306 Admission (highest level) NYC $188 vs. Hospital 99223 (highest level) $230 Mid-level follow-up care SNF SNF 99308 ($77) and 99309 ($103) vs. Hosp 99232 $82 Systems are less supportive and less efficient than hospital; resulting in lower billable visits/day. 1 new admit and 9 f/u’s/day = c. $230K direct revenues annually

7. Rehabilitation and Regenerative Medicine Patient Mix >

8. Rehabilitation and Regenerative Medicine Physician Satisfaction?

9. Rehabilitation and Regenerative Medicine Drawbacks to SNF Attending Role Lower reimbursements than IRF Less likely to receive Medical Director Stipend Non-Teaching environment Weaker infrastructure Weaker night/weekend coverage systems Weaker relationships with each patient More non-billable care, worse payor mix More medical/less rehab oriented diagnostic mix

10. Rehabilitation and Regenerative Medicine Conclusions There are good reasons why physiatrists have been reluctant to assume primary attending responsibility in SNF’s/Subacute Rehabs If IRF care shrinks, PM&R may find itself marginalized in post-acute rehabilitation unless we shift our paradigm