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When Richard Pearson shattered his tailbone a month ago and underwent surgery, there was no question he would move from one part of NCH Naples Downtown Hospital to another, the inpatient rehabilitation center.

There, the 79-year-old has different types of therapies every day until his treatment team determines he can return home to continue his recovery.

His timing couldn’t have been better.

Had he fallen and injured himself after Oct. 1, his odds for getting admitted to the inpatient rehabilitation center would have gone down - even more so when October 2008 rolls around.

That’s unless Congress intervenes against a Medicare regulation that’s been getting phased in since 2004 that increasingly restricts inpatient rehabilitation admissions.

“I think it’s lousy,” Pearson said. “I don’t think they should be limiting the people at all. I don’t know what I would have done.”

The rehabilitation industry is at wit’s end, saying enough is enough. The regulation is in the midst of a four year rollout period where the admissions quota gets more restrictive each year. The rehabilitation industry is asking for a break and has gone to Congress since officials at the Centers for Medicare and Medicaid have turned a deaf ear.

“It’s really affecting our future and it’s affecting the future of patients in Collier County,” said Heather Baker, administrator of rehabilitation services at NCH, which has a 60-bed rehab unit.

“It used to be doctors wrote an order for rehab and it was a done deal. Today patients for similar conditions can’t be admitted and they don’t understand why.”

At issue is the federal government enacting a complex change in how Medicare pays inpatient rehabilitation centers at hospitals. The change spells out the patient mix allowed, with the intent to make sure the appropriate type of patients are getting admitted for the level of care provided at inpatient rehabilitation centers.

In the first year, 50 percent of patients admitted had to fit into any one of 13 categories of medical conditions and the rest did not. In 2005-06, the quota went up to 60 percent and for this current year, the government agreed to freeze the case-mix requirement to 60 percent.

But come this Oct. 1, the required patient-mix goes to 65 percent, which means fewer patients who don’t fit into one of the 13 categories of medical conditions can be admitted. In October 2008, the patient-mix requirement jumps to 75 percent.

Worse, another rule element kicks in October 2008. A secondary illness, or co-mobidity, that’s been allowable to meet the patient-mix quota for admission can no longer count. That will further restrict inpatient rehabilitation access.

“It’s narrowing the universe of patients who will be admitted,” said Walter Ittenbach, executive director of the 60-bed inpatient rehabilitation center at Lee Memorial Hospital near downtown Fort Myers. “This is really significant.”

If a rehabilitation center admits more patients outside the allowed categories of medical conditions, the center can lose its Medicare designation as an inpatient rehabilitation center with higher reimbursement. The center would be downgraded to being an acute-care unit at a hospital at a lower Medicare reimbursement, Baker said.

The patients who cannot be admitted to inpatient rehabilitation would likely be sent to a skilled nursing home, which doesn’t necessarily have the same level of care, or the patients would stay longer on an acute-care floor.

“CMS is paying for their care one way or another,” Baker said. “If patients are not moving into rehab, the discharge planner at the hospital has to look at the rest of the community.

“We have no other rehab hospital (in Collier County) so some patients would stay in the hospital and clog up beds.”

“It adds a whole new piece to the decision process that doesn’t need to be there,” said Karen Judd, clinical director of rehabilitation services with NCH. “It’s arbitrary.”

The American Hospital Association, among others, has lobbied Congress to provide relief to the regulation after a review of its impact has shown many more patients than what the government anticipated are getting turned down from inpatient rehabilitation programs.

CMS had projected 1,170 patients would not be admitted in 2005, but the Federation of American Hospitals estimates the number is between 25,000 to 40,000 patients a year, according to an external audit.

In a health-care bill that the House and Senate have passed, there is a provision that would permanently freeze the patient-mix requirement to 60 percent and allow secondary medical conditions to count toward meeting the threshold.

The problem is that President Bush has said he intends to veto the bill, which addresses children’s issues, among other things, said Ittenbach, with Lee Memorial’s rehabilitation center.

Lee Memorial’s rehabilitation center admitted 1,350 patients in 2004 and projects it could only admit 878 patients in 2008 when the full weight of the regulation, at the 75-percent patient mix, is slated to kick in unless Congress acts, he said.

Half of the 60-bed center’s beds are occupied now and that would decrease to 40 percent occupancy under the “75-percent rule,” he said.

“We will continue to provide the service,” he said. “We will have to downsize and rightsize our service.”

NCH’s rehabilitation center in 2004-05 was unable to admit 444 patients to the rehab center because of the patient-mix quota, Baker said.

“We saw a 26 decline in admissions at NCH over that time,” she said. “The co-mobidity component accounts for 7.3 percent of our population so we would lose those, too.

“The rehabilitation industry is saying the (patient-mix rule) has dramatically gone beyond what CMS anticipated. We asked CMS to slow it down but they are not, so we went to Congress.”