Rehabilitation care (rehab) is often required after surgery or major illness in order restore physical or cognitive functionality. Patients are admitted directly from an acute facility; often the rehab unit is located within the acute care facility (69% of all admissions to rehab units in 2008 were from acute care in the same facility) (CIHI 2011a). Median wait times are from 0 days for general facilities to 1.0 days for specialty facilities; median length of stay for general and specialty facilities are 13 and 30 days, respectively, though it should be noted that these all vary depending on Rehabilitation Client Groups (RCG) (CIHI 2011a). RCGs categorize patients based on limitations to activities and/or participation as a result of a specific set of conditions, e.g., stroke, arthritis and developmental disabilities.
Funding rehab care: Canada
Currently, rehab is funded in Canada on a global budgets basis. These budgets are generally based on the number of beds allocated for rehabilitation care and specific programmatic or policy targets. While grouping methodologies have been developed for rehab care in Canada (Sutherland & Walker 2008), upon which an episode-based funding system could be developed (Carter et al 130), there are no provinces that have implemented this.
Funding rehab care: International examples
The United States’ Medicare system and Australia are two of the few countries that fund rehabilitation care through an episode-based payment system, commonly referred to as prospective payment (Eager et al 1997; Grimaldi et al 2002).
United States
Up until the early 2000s, the Medicare system in the United States remunerated rehabilitation facilities based a cost per episode. An explosion of growth lead the government to move to a prospective payment model. Under this prospective payment model:
- Patients are classified into one of 21 rehabilitation impairment categories (RIC) depending on whether they fall under the 100 unique Case Mix Group (CMG) classification system.
- Depending on this classification, patients are assigned a relative cost weight, which ascribes a cost of caring for that patient relative to the cost of caring for the average patient.
- Medicare then pays rehab providers based on the number of patients and their relative cost weights (with various adjustment made) (Thompson & McCue 2010).
The consequences of this change depend on the type of provider (i.e., for-profit, nonprofit) and clinical group. In general, however, the introduction of the prospective payment system has:
- Reduced lengths of stay
- Increased discharges
- Increased profitability (McCue & Thompson 2006; Sood et al 2008).
There are mixed effects on the per episode costs of care, with for-profit facilities seemingly being better at reducing their cost structure (McCue & Thompson 2006); this does not seem to be associated with higher mortality (Wodchis 2004).
There also seems to be mixed effects on access to care, moderated by the relative profitability of patient types (Chan 2007; Colla et al 2010). There is some evidence that quality of rehabilitative care is subject to forces of market competition (Magasi et al 2009) even though patients and families find it difficult to evaluate the quality of rehabilitation providers (Canadian Healthcare Association 2009).
The generalizability of these results to the Canadian context is difficult to ascertain. Undoubtedly, the marketplace for rehabilitation care is far different in Canada, which does not (yet) have a for-profit sector. The size and rurality of the Canadian population reduces the competitive market forces that have driven efficiencies seen in the U.S. Canada is also lacking a comprehensive data collection system. No provinces except Ontario mandate the collection of rehab-related data. Without these data, implementing a prospective payment system is not possible.
