Advances in Prospective Payment for Pulmonary Patients

Abstract

On May 19, 1987, the Health Care Financing Administration (HCFA) published changes to the Diagnosis-Related Group (DRG) classification system proposed for Federal fiscal year 1988.1Federal Register. 52(No 96): 1880-1881, May 19, 1987Google Scholar Two new DRGs for ventilator patients were proposed among the changes. One DRG would be for patients who have tracheostomy procedure codes and would be considered a surgical classification. The other DRG would be for nonsurgical patients ventilated through endotracheal tubes. Only patients with a primary diagnosis of respiratory disease would be covered. The relative payment for these new DRGs would be great since the HCFA's analysis of 1985 billing data indicated that for all respiratory patients the average charge for those on ventilators was two to ten times greater than for other patients in the same DRGs. At Rush-Presbyterian-St. Luke's Medical Center we reviewed the annual costs of 446 Medicare patients who received care in our medical intensive care unit and determined they exceeded by over $4.7 million the actual reimbursements for similar patients under the Medicare Prospective Payment System.2Butler PW Bone RC Field T Technology under Medicare diagnosis-related groups prospective payment. Implications for medical intensive care.Chest. 1985; 87: 229Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Each day on a ventilator added $439 for respiratory-related services to the total hospital costs.2Butler PW Bone RC Field T Technology under Medicare diagnosis-related groups prospective payment. Implications for medical intensive care.Chest. 1985; 87: 229Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Another study we recently completed at Rush-Presbyterian-St. Luke's Medical Center revealed that 95 Medicare patients seen over a one-year period who required prolonged ventilator care accrued costs of $3,656,137 or $38,486 per patient. This compared to Medicare payments for patients in similar Diagnosis Related Groups of $8,421 per patient.3Douglass PS Rosen RL Butler PW Bone RC DRG payment for chronic ventilator patients: Implications and recommendations.Chest. 1987; 91: 413-417Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar A similar study published simultaneously found that Medicare patients admitted to both tertiary care and community based hospitals found that mean costs per patient were $31,896 (charges $47,391) compared with Medicare payments for similar types of patients of $10,981.4Gracey D Gillespie D Nobrega F Naessens JM Krishan I The financial implications of prolonged ventilator care of medicare patients under the prospective payment system: A multicenter study.Chest. 1987; 91: 424-427Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar HCFA should be congratulated for these proposed changes, but they nevertheless address only some of the financial bias DRGs present for ventilator patients. Of the 95 patients in our study sample, only 33 were covered by the two new DRGs HCFA proposes. The remainder of the patients did not have respiratory principal diagnoses. Cost of care for patients requiring mechanical ventilation without a primary respiratory diagnosis (ie, neurologic decrease) was not less than those with a respiratory diagnosis. The potential for abuse is also great since the payment for ventilator patients receiving a tracheostomy has a much greater reimbursement than those who need prolonged endotracheal intubation. Studies have shown that the complications of a tracheostomy are greater than those of long-term intubations by endotracheal tube.5Stauffer JL Olson DE Petty TL Complications and consequences of endotracheal intubation and tracheostomy—A prospective study of 150 critically ill adult patients.Am J Med. 1981; 70: 65-75Abstract Full Text PDF PubMed Scopus (881) Google Scholar HCFA recognizes the potential for abuse and will monitor this possibility closely.1Federal Register. 52(No 96): 1880-1881, May 19, 1987Google Scholar Despite some potential problems, this legislation has important implications for our patients. The potential for patients to be disenfranchised from medical care is less after these changes are enacted. Reimbursement for care in the intensive care unit will also more closely approximate the costs of medical care. The HCFA is to be congratulated for this move. Also, our professional societies have used their legislative influence to lobby to get needed reimbursement to prevent a bias against critical care and for patients cared for in specialized units. The Government Liaison Committee of the American College of Chest Physicians has been particularly vigorous in efforts to acquaint national legislators with current inequality in the reimbursement policies. The official journal of ACCP, Chest, has provided a national forum for data which was of assistance to HCFA as they evaluated current practices.2Butler PW Bone RC Field T Technology under Medicare diagnosis-related groups prospective payment. Implications for medical intensive care.Chest. 1985; 87: 229Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 3Douglass PS Rosen RL Butler PW Bone RC DRG payment for chronic ventilator patients: Implications and recommendations.Chest. 1987; 91: 413-417Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar These efforts are to be congratulated.