Method of Medicare reimbursement and the rate of potentially ineffective care of critically ill patients
D. J. Cher and L. A. Lenert
Division of General Internal Medicine, Palo Alto Veterans Affairs Health Care System, CA, USA.
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.
Identifying Potentially Ineffective Care in the Sickest Critically Ill Patients on the Third ICU Day
Afessa et al.
Chest 2004;126:1905-1909.
ABSTRACT
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Critical Care Use during the Course of Serious Illness
Iwashyna
Am. J. Respir. Crit. Care Med. 2004;170:981-986.
ABSTRACT
| FULL TEXT
Risk Assessment for Inpatient Survival in the Long-term Acute Care Setting After Prolonged Critical Illness
Dematte D'Amico et al.
Chest 2003;124:1039-1045.
ABSTRACT
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Hospice Use Among Medicare Managed Care and Fee-for-Service Patients Dying With Cancer
McCarthy et al.
JAMA 2003;289:2238-2245.
ABSTRACT
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Managed Care, Hospice Use, Site of Death, and Medical Expenditures in the Last Year of Life
Emanuel et al.
Arch Intern Med 2002;162:1722-1728.
ABSTRACT
| FULL TEXT
Can Health Care Costs Be Reduced by Limiting Intensive Care at the End of Life?
LUCE and RUBENFELD
Am. J. Respir. Crit. Care Med. 2002;165:750-754.
FULL TEXT
Demands of an Aging Population for Critical Care and Pulmonary Services
Lynn et al.
JAMA 2001;285:1016-1018.
FULL TEXT
Community Physicians Who Provide Terminal Care
Hanson et al.
Arch Intern Med 1999;159:1133-1138.
ABSTRACT
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Managed Care and End-of-Life Decisions: Learning to Live Ungagged
Kuczewski and DeVita
Arch Intern Med 1998;158:2424-2428.
FULL TEXT
Potentially Ineffective Care in Intensive Care
Riley et al.
JAMA 1998;279:651-654.
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FEWER FUTILE MEASURES FOR HMO PATIENTS?
JWatch General 1997;1997:5-5.
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