Victims of Nation’s ‘No Care Zone’ : Report on Aging Says Hospitals Forced to Drop Elderly

Hundreds of thousands of American old people, discharged prematurely from hospitals, may be the first victims of abuse and neglect in what a research team here calls the “newest institution”--the elderly’s own homes.

They are old people who, because they can’t afford increasingly costly home-care services provided by private companies, are falling into what the UC San Francisco team calls a “no care zone.”

Being Bumped Down

In this rapidly evolving system, the UC team charges, sick old people are being “bumped down” from hospitals to such agencies as senior citizen centers that are not designed to treat acute illness and are having growing difficulty finding money to replace revenues lost in other government cutbacks.

And what is happening, according to the report by the university’s Aging Health Policy Center, is already resulting in an increasingly stratified health care system for the old. It is rapidly becoming, the researchers say, a system in which the elderly who have some access to money beyond what is paid by the government’s Medicare and Medicaid programs can find adequate medical services but those who must rely only on the government programs are left to shift for themselves.

The report is the first to publish results of at least 15 research projects now under way that are attempting to answer a series of bothersome questions about revisions in the Medicare program instituted in 1984 that changed the way hospitals are paid by the federal program.

Reimbursement Scheme

In the new system, hospitals receive a set amount per patient depending on the person’s diagnosis. A hospital receives a set fee, no matter how long the patient is hospitalized or what complications may occur. The reimbursement scheme, called Diagnosis Related Groups, or DRGs, permits no financial variation between cases of the same illness or disorder, even though there may be vastly different problems caring for any two patients with the same diagnosis.

Legislation establishing the new payment system was fought by social service agencies and advocacy groups who charged it would quickly lead to a system in which the elderly are discharged from hospitals “sicker and quicker” than ever before. But until now, there has been little in the way of measurable results of the shift in payment on which to base intelligent conclusions.

The Rand Corp., based in Santa Monica, has organized its own major study of the effects of the DRG system. But researchers there have declined to discuss the project so far, saying no measurable results are expected from the review for at least another year.

And clearly, agreed Carroll Estes, director of the Aging Health Policy Center, the new UC report relies entirely on the impressions of 335 agencies caring for the elderly in eight states whose top officials were questioned by research investigators. Estes was a principal investigator for the survey.

The states were California (where program officials in Oakland, Riverside, San Diego, San Francisco, San Jose, Santa Barbara and Stockton were questioned), Florida, Massachusetts, Missouri, Pennsylvania, Texas, Washington and Wisconsin.

The new study contains little in the way of hard numbers--firm financial measurements or clinically certain accounts of worsening of physical ills among the old. Nevertheless, said Dr. Philip R. Lee, the nationally known director of UC’s Institute for Health Policy Studies and the other principal investigator in the new aging report, “the data are very reliable. This constitutes an early warning system.”

The report found that agencies of all types experienced major increases in the number of old people seeking their help between 1983 and 1984. The biggest increases were reported for people 75 or above, with home health, nutrition and information and referral agencies reporting the biggest gains. There was a 70% jump in the number of agencies reporting people 75 to 84 seeking nutrition assistance, with nearly as much of an increase in the home health field.

The increase in demand is so great that, at one program surveyed, the San Francisco Visiting Nurse Assn., officials said that in a meal program that serves 750 old people a day, new admissions are being restricted to economic emergency cases and that, even with that constraint, there is still a three-month waiting list to get in.

Agreement of Studies

Though its data, the UC researchers agree, is soft, the report generally reaches conclusions similar to two other early studies--by the U.S. General Accounting Office and the American Society of Internal Medicine. Together, the three documents sound what Estes said is an alarming warning signal that the new DRG payment system may already have begun to produce these results:

--Sick old people, discharged prematurely from hospitals, are depending for their care on spouses and friends who may, themselves, be in poor health and unable to withstand the physical rigors of caring for an acutely ill person. The 335 agencies questioned, Estes said in an interview, have noted a sharp increase in the number of strokes and heart attacks suffered by elderly care-givers, resulting in acute care hospitalizations for the companions as well as possible costly rehospitalization of the patient discharged too soon.

--Federal programs that previously provided a range of health services in existing full-service senior citizen centers have been cut back, leaving the elderly poor who cannot afford supplemental insurance to shift for themselves, often essentially trapped in their homes or apartments. Some federal money is still available for special quasi-medical services, like tube feeding, but such programs, the UC report says, often fail to pay any attention to such problems as basic sanitation or meals.

“The transition of the home into the ‘newest institution’ . . . may signal the emergence of a redefinition of the concept of community-based care,” the report warned. Estes said the growing number of elderly people who cannot afford such things as communal meals at senior citizen centers may well result in old people living at home with hardships and neglect as bad or worse as in 19th-Century charity hospitals or 20th-Century substandard nursing homes.

--While the dimension of the problem is as yet not clearly known, the number of old people in the potential trouble group is clearly large. Estes said that unpublished data she received from the U.S. Department of Health and Human Services indicate there are 1.2 million sick elderly people depending for their care on 2.2 million other senior citizens--the majority of them close friends, husbands and wives.

The figure is based on statistical analysis of 1982 U.S. Census population estimates. The 1.2 million may form the core, Estes said, of the growing group of old people essentially institutionalized, in squalor, in their own homes.

--At the same time, government funding for elderly health programs is disappearing, nonprofit groups are discovering the demand for private funding to replace what has been lost has vastly exceeded supply and many health-oriented senior citizen centers have stopped even applying for grant assistance because the odds of success are so low. Estes said survey data indicate that in 1983, 65% of the agencies interviewed had applied for private funds to offset government cutbacks, with 84% of those getting at least some supplemental grant assistance. But a year later, only 47% of the agencies even bothered to apply, with 78% receiving approvals.

--Medicare funding changes brought on by the DRG system have attracted private companies to many specialized home health businesses, but resulted in a drop in availability of full-service health maintenance services, including laundry and chore assistance, transportation and programs in which volunteers take over all care for sick old people so family members and other care-givers can have a break.

Growing Economization

“There is a growing ‘economization’ of health care in that (for-profit companies) are moving into the mode of home health as a business, offering only those services which are profitable, or reimbursable, and serving only those clients (who) can afford to pay by Medicare, private insurance or out of pocket,” the UC report concluded.

“These events increase the possibility that a ‘no care zone’ may be created for certain types of individuals. If there is no money in the voluntary (nonprofit) sector to supplement (government) dollars, an agency will have difficulty covering its costs for serving the poor.

“Those centers that serve the poor are being forced to contract out more services and to increasingly consolidate funds into one program--meals. This means the low-income elderly face a declining number of available services, and that the senior centers that serve them face an increasingly likelihood that they will not be able to continue in existence much longer.”

In a separate interview, Lee said that though many of the conclusions in the new UC study are based on sometimes subjective impressions of the 335 agencies questioned, the situation as it can now be perceived adds emphasis to what he has long felt is a major and disturbing question about the American health care system.

“Is medical care a market good, like tires, or is it a social good where we all benefit? We simply haven’t yet decided that,” he said.

The new UC San Francisco study mirrored earlier findings by both the GAO and the American Society of Internal Medicine, a scientific and professional organization representing primary care doctors. The society surveyed 246 practicing physicians, asking if doctors felt they were being pressured to discharge patients prematurely or use fewer tests than necessary to make a certain diagnosis.

The Washington-based society said the survey yielded more than 200 specific case reports documenting a drop in the quality of patient care under the DRG program. Under the new system, a hospital is forced into the position of predetermining an average length of stay for a specific illness. The society said doctors responding to its survey even reported seeing printed warnings on their patients’ medical charts reminding them that the statistical discharge deadline for the illness in question was to arrive within one or two days.

Strain on Families, Friends

The society said its members reported premature release from the hospital for a wide variety of conditions that coincided with the UC report’s findings of a growing strain on families and friends who are unprepared and untrained to deal with complex illnesses. Specifically, the internists said patients with Alzheimer’s disease, pneumonia, strokes, phlebitis, gallbladder and heart problems were involved.

Government figures confirm that, across the country, dramatic cuts in hospital stays and Medicare admission rates have been reported since the new system was put into place. In California, which has long had some of the nation’s most brief hospitalizations, old people on Medicare were being kept as inpatients an average of 7.56 days in 1984, down from 8.67 two years before. Nationally, the stay rate had dropped to 8.99 days from 10.3 in 1982.

Significantly, too, the rate for admissions to hospitals among Medicare patients was down all over the country, from 389 admissions per 1,000 Medicare clients in 1982 to 384 in 1984. In California, the decline was from 350 to 343.