When Dan Decker entered Magee Rehabilitation Hospital in Philadelphia last month after undergoing a heart and kidney transplant in May, he was completely immobile. "I couldn't even move my feet," he said. "Before the operation, I had been on dialysis and bedridden for six months." But after three weeks of intensive inpatient rehabilitation at Magee, Decker said he can walk and talk again and has regained almost full function. "Now my only goal is to go home and resume a normal life," said the 58-year old, who works for his family's hospice and home health agency.

Yet, transplant patients like Decker could have a tougher time accessing inpatient rehabilitation because of the Centers for Medicare & Medicaid Services' (CMS) "75% rule." The rule took effect July 1, despite intense opposition from the AHA, providers, patients and more than 300 lawmakers on Capitol Hill. Under the rule, transplant patients do not qualify toward the threshold inpatient rehabilitation facilities (IRF) must meet for payment as an IRF Medicare. Also excluded are patients recovering from cancer and from cardiac and pulmonary conditions, as well as many joint replacement patients.

The rule "just doesn't make sense" to Decker. "The people they're targeting are really debilitated," he said. "I would invite [CMS] to a rehabilitation hospital to see what people are going through, to see what they accomplish in rehab care, before they make rules like this." Decker also believes his care would have cost more had he not received inpatient rehabilitation; without it, he says, he would have had a longer acute stay and recovery process.

As patients and providers wrestle with the rule's impact on care, advocates nationwide press for a moratorium. As part of that effort, Rep. Nita Lowey, D-NY, organized a June 29 press conference in protest of the rule at a New York state inpatient rehabilitation facility. Lowey authored a bipartisan letter signed by 241 representatives last month urging the Department of Health and Human Services (HHS) and CMS to halt implementation of the 75% rule so that it can be studied and appropriately modernized by clinical experts. A companion letter was signed by 82 senators.

She was joined at last month's press event by patients, providers and hospital association representatives, including Mary Beth Walsh, M.D., CEO of Burke Rehabilitation Hospital in White Plains, NY, Raymond Sweeney, executive vice president of the Healthcare Association of New York, and Kenneth Raske, president of the Greater New York Hospital Association.

"Medicine has made great strides in the last 20 years," said Lowey in a statement issued after the event. "If the rule is not updated to reflect today's practices, it will put our local rehab facilities on life support."

Lowey's concerns also are shared by rehab hospital leaders like Janet King, who is administrative director of physical medicine and rehabilitation at Genesis Medical Center in Davenport, IA, and a member of the AHA Section on Long-Term Care and Rehabilitation. "A hospital is not told, 'You can only provide so many C-sections,'" she said. "Yet, that is was CMS is asking of rehabilitation facilities."

King said Genesis already has seen a "significant downturn" in its inpatient rehabilitation admissions and has had to lay off 13.5 of 185 full-time equivalents. The facility, which has followed a final 75% rule since it was proposed this spring in anticipation of implementation, has had to deny admission to patients to meet the rule's threshold, and area physicians have stopped referring patients they know won't qualify under the rule.

As a result, patients have had to wait for care, or instead have gone to other facilities or stayed in acute beds longer, missing the opportunity to receive the inpatient rehabilitation that can help them regain functionality and enjoy a better quality of life, King said.

King said she instead would like to see a rule that uses the "fairest, most equitable criteria, irrespective of diagnosis," criteria similar to that Genesis uses to determine whether inpatient rehabilitation is appropriate. Before admitting patients for inpatient rehabilitation, the facility screens them to determine whether they need the intensive, specialized care of an inpatient rehabilitation facility, including care by a multi-disciplinary rehab team coordinated by a physician.

Meanwhile, the AHA is working with lawmakers, like Rep. Lowey, toward a legislative resolution of the problem. Lowey, a member of the House Appropriations Committee, is considering proposing an amendment to the fiscal year 2005 HHS funding bill, which the committee is expected to consider this week. Her proposal would impose a one-year moratorium on the rule, while it is studied and modernized by the Institute of Medicine.