Change in the Health Care System
Change in the Health Care System
复制标题
医疗保健系统的变化
DOI：
--
复制
发表时间：
1986
影响因子：
6.3
通讯作者：
L. Iezzoni
中科院分区：
文献类型：
--
作者：
L. Iezzoni
Symptoms of strain in the infrastructure of the American health care system have long been growing. In particular, observers have pointed to the tremendous escalation in health care costs and cautioned that change was inevitable. But even the most prescient health policy pundit could not have predicted the pace and the course of these changes. Led by Medicare’s Prospective Payment System (PPS) enacted in 1983, numerous forces have conspired to fundamentally restructure the way health care is provided and reimbursed. Not only have new health care delivery networks, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), arisen in droves, but also conventional health insurance providers are adopting many of the reimbursement approaches of their new competitors. Throughout this melee of changes, one unifying theme is paramount: the goal of cost containment. The trademark of all these changes-PPS, HMOs, PPOs-is powerful pecuniary incentives to control costs. This change in the health care system has not occurred in isolation: with mounting budget deficits and the recent Gramm-Rudman-Hollings legislation, the consuming preoccupation of most lawmakers appears to be slashing government spending. But what are the consequences of this single-minded focus? Certainly the geriatric population will be most affected. Of all segments of our society, the elderly are a captive audience to federal policy because of their dependence on federal programs for subsistence income and for health care. Most elderly do not have the option to switch insurance plans if they become dissatisfied with the PPS. Thus, the PPS cost containment measures will affect almost all elderly citizens. Under Medicare‘s PPS, will patient care suffer? Answering this question will not be easy. On the one hand, describing the incentives inherent in the PPS is a fairly straightforward task. Medicare now pays hospitals for each admission a single, predetermined lump sum based on the average expense for a patient within a given diagnosis-related group (DRG). This system clearly encourages hospitals to avoid patients who are systematically more costly than the DRG average. It also permits hospitals to profit by incurring less than average costs (eg, by discharging patients early or by using fewer, expensive technologic interventions per admission). This incentive underlies the concern that patients may be discharged “quicker and sicker” to environments ill-prepared to receive them (such as nursing homes without adequate physician, skilled nursing, and technologic supports). It is also conceptually straightforward to describe attributes of many elderly which make them uniquely vulnerable to these incentives. For example, persons with multiorgan system disease or chronic disabilities may form the systematically expensive group to be avoided. Thus, large numbers of elderly may have trouble gaining access to care. Many elderly may lack family or personal support networks for post-hospital care or active advocacy within the inpatient setting. The majority of elderly live on fixed incomes, with little leeway for major health expenditures (eg, for prolonged nursing home care after an early hospital discharge). However, extrapolating from theoretical incentives to actual practice is a more difficult undertaking. In addition, given the apparent pressing need for federal budgetary restraint, the burden of proof seems to have shifted to those claiming a negative impact of the PPS on quality of care. There are significant impediments to producing this proof. First, changes in the current health care system are both numerous and rapid. Nothing stands still long enough to permit thoughtful, well-controlled study; and changes in one area cut across those in another, so that it becomes impossible to disentangle specific features of the system which cause the negative outcome. Second, the present mood requires persuasive proof-anecdotal evidence may provide hints of trouble spots but may not be accepted by beleaguered lawmakers and bureaucrats as the basis for shifts in policy. In the past, evidence on health policy questions has been pursued down two major pathways,
