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May 1998
Method of Medicare Reimbursement and the Rate of Potentially Ineffective Care of
Critically Ill Patients.
Cher DJ and Lenert LA;JAMA 1997;278:1001-1007.
[ see abstract below ]
Anesthesiologists are often involved in ICU care. Our technical expertise is often sought for cardiopulmonary management, pain relief, and/or intraoperative care of these very sick individuals. Are we actually helping our patients?
The authors suggest that the worst outcome of critical care may not be dying, but an extended death process. They hypothesized that ineffective care would be more
prevalent in fee for service Medicare patients than for those enrolled in HMO's.
This is not due to heinous behavior on the part of fee for service physicians,
but by the fact that there is no one reviewing the use of potentially
ineffective care and saying, "Enough is enough. This is a waste of resources."
On the other hand, they were also concerned that being stingy with potentially
ineffective care (PIC) might lead to a decrease in appropriate care, so they
compared death rates between these groups also.
Potentially ineffective care (PIC) was defined as total hospital costs above the
90th percentile combined with in-hospital death or death within 100 days of
hospital discharge. Basically, this says society expended a small fortune and it
didn't help the patient.
Almost 5% of patients experienced PIC, and consumed >20% of all ICU resources.
Costs, hospitals, and patient groups were well standardized for comparison. The
methods accounted for age, institution (academic, number of residents, cost to
charge ratios, local wage indices, etc.), age, sex, race, disease severity, and
how often common ICU diagnoses were treated at a particular hospital. HMO
patients were much less likely to receive PIC. PIC was given 3 times to HMO
patients for every 4 times in Medicare fee for service patients. In-hospital
death was no different. Death within 100 days was minimally higher (1.08) in HMO
groups for every one in Medicare fee for service.
This work expanded the traditional definition of successful ICU care from
preventing in-hospital death to preventing in-hospital death OR a lingering
death within a short time of hospital discharge. Previous studies only looked at
in-hospital death and did not see a difference in HMO's and fee for service.
This new approach has yielded a positive finding. Perhaps we all need to
reconsider how we care for the aged and terminally ill. We want to make sure we
are helping them, not prolonging agony. The results of this study suggest that
individual physicians are particularly good, not as good as HMO's, at seeing
when more care is worse than no care.
Much of PIC is apparent early in a patient's course. When intensive medical
therapy results in a worsening severity of illness (by APACHE scale criteria),
further care will often not help the patient. The problem is deciding for any
ONE individual. The population at large does not seem well treated by our
approach. But, an individual does not care about a theoretical "population." We
are talking about denying care with a guaranteed result of death. An HMO might
feel comfortable doing that. Most physicians do not. That is a pure and basic
difference between letting HMO's and doctors run the show. Instead of abdicating
our responsibility to consider resource utilization, maybe we should find a
better way than denying care by population criteria (like HMOs).
Perhaps we should allow more active patient input. We too often sugarcoat the option of
further medical therapy by saying it might work, there's still a chance. What
does that mean? Let our patients and their families consider a realistic (and
realistically grim) portrayal of what suffering will attend further aggressive
medical care, and how likely that care is to fail to help them. Then, let it be
their decision. After all, it is their life.
Return to the Current Literature Review Front Page, or read the abstract:
ABSTRACT
CONTEXT: The worst outcome of critical care may not be death itself; rather, the worst may be an extended death process in which a patient's and his or her family's suffering has been prolonged by services that are ultimately impotent. We have previously used potentially ineffective care (PIC) as a proxy measure for this type of care.
OBJECTIVE: To determine if PIC is delivered less often to Medicare patients enrolled in health maintenance organizations (HMOs) than those in traditional fee-for-service health plans.
PATIENTS: All Medicare patients hospitalized in intensive care units in California during fiscal year 1994.
OUTCOME: Potentially ineffective care was defined as the concurrence of in-hospital death or death within 100 days of hospital discharge and resource use (total hospital costs) above the 90th percentile.
METHODS: Hospital costs were adjusted for institution-specific cost-to-charge ratios and local wage indices derived from Health Care Financing Administration cost reports. A multivariate regression model adjusted PIC rates for age, sex, race, elective admission to the hospital, Charlson index diseases, the 15 most common diagnosis related groups for death by 100 days, intensive care unit size, and number of residents at the hospital.
RESULTS: A total of 3914 (4.8%) of 81 494 patients experienced PIC and used 21.6% of total intensive care unit resources. The occurrence of PIC was less common among HMO members (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87). However, HMO members were not more likely to experience in-hospital death (adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.07) and only slightly more likely to experience death by 100 days after hospital discharge (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.15).
CONCLUSIONS: Patients who experience PIC outcomes are not uncommon in the Medicare population, and patients experiencing this outcome consume a disproportionate amount of medical resources. Medicare beneficiaries in HMO practice settings had a lower risk of experiencing PIC outcomes after adjusting for age, sex, diagnosis, comorbid conditions, and characteristics of the treating hospital. This suggests that HMO practices may be better at limiting or avoiding injudicious use of critical care near the end of life.
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