The prospective payment system and quality: no skeletons in the closet

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 receive a fixed-fee prospective payment for each patient, based on the patient's diagnostic related group (DRG). Concerns have been raised that the PPS could encourage cost-cutting and erode the quality of care or increase mortality. A summary of the studies' results is presented. Mortality rates up to 180 days after admission did not increase after the PPS, nor did readmission rates rise. However, more patients were discharged to nursing homes, rather than back to their own homes. More patients (from 15 percent, pre-PPS, to 18 percent, post-PPS) were also discharged in unstable condition; however, data regarding the follow-up of these patients by physicians are lacking. No direct negative effect of the PPS on the process of care was found for the five conditions studied (congestive heart failure, heart attack, pneumonia, cerebrovascular accident (stroke) and hip fracture). The possibility that the PPS influences the quality of care in other ways than its DRG payments, such as by preventing hospitals from growing, was not addressed. On the whole, the articles present improved methods for assessment of the quality of care for hospitalized patients. That 17 percent of the patients studied received poor or very poor care, is cause for concern. The determination of different weights for various physiological variables (blood pressure), depending on the underlying disorder, is a valuable contribution to methods of estimating disease severity. In summary, the PPS does not appear to have done harm to Medicare patients; if problems develop, they will undoubtedly result from interactions between the PPS and other forces in the US health care system. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Mortality, Statistics, Hospitalization, Hospital patients, Medicare, Hospital care, Prospective payment systems (Medical care), editorial

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The appropriateness of hysterectomy: a comparison of care in seven health plans

Article Abstract:

A consortium of seven health maintenance organizations examined the rates of inappropriate hysterectomy as a means of evaluating quality of care provided by different health plans. A panel of physicians rated the appropriateness of hysterectomy given various indicators and clinical scenarios, and these ratings were used to assess the appropriateness of hysterectomies actually performed at the seven organizations. Of 642 non-emergency, non-cancerous hysterectomies, 58% were performed for appropriate reasons, 25% were performed for uncertain reasons and 16% were performed for inappropriate reasons. Most of the inappropriate operations were among the younger women. The proportion of hysterectomies done for inappropriate reasons ranged from 10% to 27% at the different organizations. One of the organizations had a significantly higher proportion of inappropriate hysterectomies (29.4%) than the group average. Information provided by the consortium may be useful to regulatory agencies, corporate purchasers and the public.

Usage, Health maintenance organizations, Hysterectomy

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• Abstracts: Prospective payment system and impairment at discharge: the 'quicker-and-sicker' story revisited. Changes in sickness at admission following the introduction of the prospective payment system
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