WASHINGTON -- Faced with the very real possibility their Medicare payments will be cut this fall, nursing homes are beginning to think about what if. . .

At Integrated Health Services in West Palm Beach, that could mean rehabilitation therapy sessions will be trimmed from an hour to 45 minutes. Or from five days a week to three.

At the Joseph L. Morse Geriatric Center, also in West Palm Beach, it's the quality of life services that are likely to suffer: trips to the Kravis Center; nights out at restaurants; weekly performances by outside entertainers or the monthly "bistro" where tuxedo-clad staffers serve upscale meals to residents and their families.

Unless Congress acts before Oct. 1, nursing homes will face a 17 percent cut in Medicare payments -- $3 billion a year -- that they say will threaten the quality and availability of care. Florida's 650 nursing homes would see a $218 million reduction if the cuts take effect, according to the American Health Care Association.

"I'm scared to death because. . . that's going to affect my mother, and your mother, and your grandmother," said Charles H. Roadman II, the president of the association, which represents about 12,000 for-profit and nonprofit long-term care facilities.

"These cuts amount to $60 per patient, per day and will threaten the quality of patient care, limit beneficiary access to needed services and perpetuate the nursing staffing crisis by eliminating important health care jobs," Roadman said.

Congress set the stage for the cuts a few years ago. Faced with burgeoning nursing home spending, Congress and the Clinton administration agreed in 1997 to reduce the growth in Medicare by $9. 2 billion over five years by adopting a new rate schedule.

But when the schedule took effect, it caused payment levels to drop nearly twice as much as expected. The impact on nursing homes was devastating. More than 8 percent of the nation's 16,600 nursing homes were operating under Chapter 11 bankruptcy protection at the end of last year.

The quality of care also suffered.

"The implementation of the new Medicare prospective payment system. . . was associated with a reallocation of nursing staff, characterized by decreased (registered nurse) hours for the majority of (nursing homes). . . and a heavier reliance on lower-cost nursing staff," according to a recent study by the University of North Carolina School of Public Health.

In response, Congress adopted laws in 1999 and 2000 that partially restored the cuts.

One provision increased payment rates 4 percent across the board. Another boosted one of the components in computing rates by 16. 6 percent. Yet another added a 20 percent increase in payments for patients requiring complex medical care such as ventilators and intravenous tubes.

But those increases carried expiration dates. The 4 percent and the 16. 6 percent boosts are scheduled to expire on Sept. 30. The 20 percent increase is supposed to be revised to affect only a small number of complex care patients. When that will happen is uncertain, but President Bush's budget anticipated it will be in the budgetary year beginning Oct. 1.

Mark McClellan, Bush's health policy adviser, said the increases "were always intended by Congress to be temporary," until the new payment structure could be devised.

But John Schaeffler, the American Health Care Association's vice president for legislative affairs, said the restructuring plan will increase rates for only a handful of categories while reducing complex medical care payment rates overall by about 20 percent.

Making the temporary increases permanent is one of the nursing home industry's top legislative priorities. Nursing homes and advocates for doctors and hospitals are all pushing for another Medicare restoration bill -- similar to those of 1999 and 2000 -- that will further offset the 1997 cuts. So far, Congress hasn't considered such a bill, but that usually does not happen until near the end of the session in the fall.

Medicare covers about 10 percent of nursing home patients who are there for rehabilitation or skilled nursing care after being released from a hospital. The average stay for such a patient is 28 days. About two-thirds of nursing home patients are covered by the federal-state Medicaid program, whose payment rates are notoriously low.

Cuts in Medicare payments are felt by all nursing home residents, said Scott Boord, Morse's senior vice president and chief operating officer.

"We're so heavily regulated by the state and federal governments, we can't take any shortcuts in terms of providing the care they need," Boord said. "The issue is what is the effect on everybody here?"

The combination of higher costs and lower payments makes it difficult to balance the budget. That means looking at some of the extra services, such as trips, entertainment and classes.

"We never want to become a home that provides just the regulated services," Boord said. "If Morse can't provide those value-added services that make this facility a resident's home, then we're no longer fulfilling our mission."

Adela Baldo, administrator at Integrated Health, a for-profit home, said she worries the Medicare cuts could mean reducing services for the home's 120 patients.

Services would not be eliminated, but the amount of time given for each service -- such as rehabilitative therapy -- might be reduced, she said.

"I think sometimes they forget in Washington that we're dealing with human beings," Baldo said. "If they continue to not provide the money, how can I provide the quality therapists?

"We can't cut corners," she said. "We need to provide these patients what they deserve, what they come here for."