No Decline Noted in Hospital Care for Medicare Patients : Health: But RAND Corp. and UCLA researchers also say more elderly were discharged in ‘an unstable condition’ under the government’s new payment method.
A 1983 change in the method of paying hospitals under Medicare “did not interrupt” a long-term trend toward better hospital care for the nation’s elderly, according to an extensive study by researchers at the Santa Monica-based RAND Corp. and UCLA Medical Center.
But the team, led by Dr. Katherine L. Kahn and Dr. Robert H. Brook, found that some of the gains in hospital care were lost because the changed payment method “has increased the likelihood that a patient will be discharged home in an unstable condition.”
Eight articles based on the RAND study are being published in today’s issue of the Journal of the American Medical Assn. The Times reported most of the major RAND findings in April, 1989, when they were presented at a medical meeting.
The percentage of patients judged to have received “poor” or “very poor” hospital care decreased from 25% in 1981-82, before the change, to 12% in 1985-86, after the change, Kahn said. But the percentage of patients sent home with at least one “instability” increased from about 10% to about 15%.
Elderly patients discharged with rapid heart beat, confusion or other instabilities have higher death rates within 90 days of discharge than patients without such problems, the researchers determined.
Under the “prospective payment system,” Medicare pays hospitals a fixed sum, set in advance, for each patient who is admitted. Previously, under a “fee-for-service” system,” hospitals had billed Medicare for each service they performed. The goal of the new system is to cut costs while maintaining quality medical care.
The $3.9-million, four-year RAND study involved a detailed review of the medical records of 14,012 patients.
In an interview, Kahn cautioned that since data collection was completed in 1986, “the financial screws on hospitals have been tightened.” She added, “I really don’t know what the quality of care is like now,” and called for continuing studies.
Gail R. Wilensky, administrator of the Health Care Financing Administration, which is responsible for Medicare and which funded the study, took heart in the RAND conclusions.
In an editorial for the medical journal, Wilensky said the findings “should inspire caution in those critics who have attributed most recent hospital problems to the prospective payment system and who would have unhesitatingly attributed decreased quality to (the payment system).” But Wilensky acknowledged that improvements in quality of care for the elderly do “not appear to be directly attributable to the (changed payment system).”
The patients studied had one of five conditions common in the elderly--congestive heart failure, heart attack, pneumonia, stroke or hip fracture.
Among other findings:
* Elderly patients admitted to the hospital after the change in payment system tended to be sicker than those admitted to the hospital before the change.
* As of 30 days after hospital admission, the overall death rates were similar--16.4% in 1981-82 and 15.4% in 1985-86. By 180 days after hospital admission, 29.6% of of the patients studied in 1981-82 were dead, compared to 29.2% of the patients studied in 1985-86.
* Medicare patients judged to have received “very good” quality of care had a 17% mortality rate as of 30 days after hospital admission, compared to a 30% mortality rate for patients judged to have received “very poor” quality of care.
BACKGROUND
In October, 1983, the federal government changed the way it paid hospitals under the Medicare program, which insures the elderly and disabled. The change raised concerns that the quality of hospital care would decline. Previously, under a “fee-for-service” system, hospitals made their own decisions on treatment of elderly patients, and then billed Medicare. Since 1983, Medicare has paid hospitals a fixed sum, set in advance, for each patient. The goals of this “prospective payment system” are to encourage efficient medical care while discouraging prolonged hospital stays and excessive tests and treatments.
