Prospective payment in French post-acute care: Comparison to international funding of rehabilitation systems.

OBJECTIVE: In all countries, the boundaries are ambiguous between acute and post-acute as well as defining the dimensions of care. The aim of this study is to analyze relations between segmentation of care and payment systems. In the new prospective payment system implemented in French SSR, the grouping unit is inpatient stay and the week for day hospitalization. In 1991, the field of SSR mixed structures as diverse in their purposes as public or private hospital units of rehabilitation and "nursing homes". A case payment must necessarily be based on a classification describing homogeneous procedures and costs involved.

MATERIAL/PATIENTS AND METHODS: The post-acute care systems in Anglophone and Francophone countries were compared using 5 dimensions: segmentation of care, orientation criteria, information tools, case mix classifications and performance criteria.

RESULTS: Most countries segment hospital stays in acute and post-acute. The graduation of post-acute care levels is primarily based on the potential for rehabilitation. The specific and very specific levels are specialized by pathology, by type of disability or social inclusion goals. Most systems distinguish missions of rehab centers including geriatric vocation, focusing on functional status and nursing homes for intermediate or transitional care. They hybridize financing cases tailored to rehabilitation programs and funding to the weighted day with activity, for the unstable patients with less predictable lengths of stay for other non-acute care purposes. Bundled payments are under consideration in the US.

DISCUSSION - CONCLUSION: France has segmented the SSR in a vertical integration with the categories of acute care. Graduation is ambiguous. The current segmentation fails to articulate a case mix classification system to a meaningful scale of tariffs, lack of grouping into homogeneous. A per case payment implies a redefinition of SSR distinguishing the relevance of functional restoration centered care, intermediate care or medical and social transition.