Prospective payment system and impairment at discharge: the 'quicker-and-sicker' story revisited

Article Abstract:

The effects of the prospective payment system (PPS) for Medicare patients are evaluated in a series of articles in the October 17, 1990 issue of JAMA, The Journal of the American Medical Association. Under this system, hospitals are paid a fixed rate for each patient, based on the patient's diagnostic category. One allegation regarding the effects of the PPS is that patients leave the hospital ''quicker and sicker'' than in pre-PPS days; this was tested by studying levels of impairment at discharge for a sample of 10,913 Medicare patients. The patients had been admitted for congestive heart failure, heart attack, pneumonia, cerebrovascular accident (stroke), or hip fracture. Three measures of impairment were adopted: instability, sickness, and abnormal laboratory results. Measures of instability generally involved conditions that had not been present at admission that ought to be corrected prior to discharge or monitored afterwards. Results showed that, during all years studied, 17 percent of patients were discharged with at least one instability; 39 percent had at least one sickness measure; and 24 percent had an abnormal last laboratory value. People discharged to institutions, rather than home, had higher levels of all three measures. Those discharged with one or more instability had a greater chance of dying (16 percent) within 90 days than those without instabilities (10 percent); patients admitted for hip fracture had the greatest risk of death within that time. Before PPS, 15 percent of discharged patients were unstable; afterwards, the rate was 18 percent (an increase of more than one fifth). The increase in instability was mostly among people discharged home, and was particularly great for hip fracture patients (a 93 percent increase). While 85 percent of patients leave the hospital in stable condition, the results indicate that some patients are being discharged too early, leading to higher death rates. The data analyzed are already four years out of date, and reimbursement levels have dropped still further in that time; the problem is undoubtedly more serious now, and demands resolution. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Health facilities, Hospital patients, Hospital admission and discharge

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Changes in sickness at admission following the introduction of the prospective payment system

Article Abstract:

The effects of the prospective payment system (PPS) for Medicare patients are evaluated in a series of articles in the October 17, 1990 issue of JAMA, The Journal of the American Medical Association. Under this system, hospitals are paid a fixed rate for each patient, based on the diagnosis. The current report presents measures of sickness at admission for five diseases: congestive heart failure, heart attack, pneumonia, cerebrovascular accident, and hip fracture. Several sources were used to develop 73 sickness variables relevant for mortality, including literature review, clinical judgment and disease-specific consensus panels. Nineteen variables were chosen as most relevant for measuring sickness at admission. These, with their weightings in terms of ability to predict mortality, are presented in tabular form. The same variable (for instance, blood pressure) has a different weight in predicting death for patients admitted with congestive heart failure than for those with hip fracture. Patients in the healthiest and sickest quartiles (based on these scales) had the lowest and highest death rates, respectively, at both 30 and 180 days after admission. Following the introduction of the PPS, sickness at admission increased substantially: the 30-day mortality for all five diseases was one percent higher from 1985 to 1986 than from 1981 to 1982. Patients with pneumonia had the greatest increase in expected mortality. The predictive abilities of the APACHE II scale (Acute Physiology and Chronic Health Evaluation), the Mortality Predictor System (MMPS), and several other frequently-used indicators, are evaluated for this group of elderly patients. The reasons patients are sicker than before PPS are not clear; if anything, the new system should encourage hospitals to take healthier people. Increased participation by paramedical services, which keep people alive to be hospitalized, may be one explanation. (Consumer Summary produced by Reliance Medical Information, Inc.)

Analysis, Health status indicators

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