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Hospital stays for Medicare patients are usually covered by a flat fee, based on the Diagnosis-Related Group (DRG). The DRG system was designed to group patients with similar resource consumption and length of stay patterns into categories with a set rate for reimbursement. For example, a Medicare patient who enters the hospital with bronchitis and asthma and experiences complications will be assigned to DRG 96, and the hospital will receive an average payment of about $3,280.
Hospitals are at special risk when initiating end-of-life care services. There are some striking examples of inpatient services with designated beds that have published information about good outcomes and sustainable finances (von Gunten, et al. 1998). When organized as inpatient hospital services, however, these programs risk eventual investigation of whether some of the patients served really had to have been in the hospital. The question of who should be in the hospital is obviously central to the question of whether Medicare should pay a DRG for the hospital stay, but there is no settled answer. Essentially, a fiscal intermediary can make a patient-by-patient judgment, and the hospital has to take on the burden of appeal. Formally, the fiscal intermediary can allege that the patient was in the hospital but not receiving services that required hospitalization (sometimes proposing that the person could have been served in a skilled nursing facility, sometimes simply that the person could have been served somewhere else). In either case, reimbursement for the stay is denied. Usually, the hospital cannot collect from the patient, so this situation presents the possibility for substantial bad debt. A patient who is in the hospital and receives opioids for pain management, along with family support and chaplain services (and no surgery, consultations, diagnostic procedures, etc.), seems to be a person at risk of such "downgrading" from hospital-level reimbursement.
Creating a service or unit that might concentrate such patients might well be risky. It seems that everyone knows of a case like this happening somewhere, sometime, but no one knows the rate or the degree of risk. Financial risks will be lower for units that have lots of "doctor-requiring" interventions on the usual patient (e.g., intrathecal anesthesia, radiation treatments, intravenous vasodilators, or inotropic drugs). In units with very short stays (such as ventilator withdrawal cases), the risks of adverse financial decisions (under fraud and abuse investigations) are reduced. However, a unit that really caters to the many patients who need close monitoring for symptoms and peaceable deaths is likely to have to organize such services as a licensed nursing facility or inpatient hospice rather than as a hospital.
In addition, hospital management might well have to consider the financial effect of strategies for caring for end-of-life patients - especially since these strategies can reduce hospitalizations. Some disease management approaches in congestive heart failure have cut hospitalization by more than half (Rich, 1999). The variation in practice patterns for treatment of dementia and frailty of old age is quite substantial. If a hospital is in a setting in which most dementia patients are hospitalized for every fever and most die with gastrostomy tubes, the management would do well to consider the financial consequences of a potential shift toward more care at home and less intensive medical interventions.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved. For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ]. |
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