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Acute Hospital Care of the Elderly: Research and . Policy Issues Stephen R. McConnell l ! While I served on He Senate-Special' Committee on 'Aging, He com- mitteeicontr~buted to raising 'the issue of quality of care to He national agenda. For a long time, the major issue in health care was cost containment; uldmately''~at win continue ' to be He chief concem. but at .. . . . least quality of care has been given some attention. .. Two critical heals concerns in Congress are how do' we contain costs and minimize jeopardy to quality-of care and access, and how do we expand protection for acute and chronic care and not break me bank. These are very difficult issues, but ~ believe that we are making progress toward answering some of the questions. Many of the participants in this forum have contributed a great deal to that progress. ISSUES DRIVING CONGRESSIONAL DECISIONS Four issues are Giving health care concerns in Congress: The growth in out-of-pocket expenditures for medical care by the elderly. Because the elderly are now paying more out-of- pocket expenses than they were before Medicare, much concern and debate are generated in Congress about how to keep Pose costs down. The reduction in average length of stay. Adjustments are re- quired elsewhere in the health care system because of this, but very little is being done to deal with the fact that people are spending less time in the hospital and more time in other set- tingssettings that we have termed the "no care zone." ~32

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ACUTE HOSPITAL CARE: RESEARCH AND POLICY ISSUES The shift from inpatient services to outpatient services. The costs of Medicare Part B are rising dramatically, pardy because more services are being provided outside the hospice under Part B. Individuals are now paying, out-of-pocket, 60 percent of physician services because they are outside the prospective pay- ment system (PPS) and, in many cases, outside any kind of monitoring system. The focus on cost containment has kept us from focusing on quality of care. Although quality of care is now on the national agenda, consumers are confilsed about many of the changes. Physicians and hospital a~nin~strators are also confused about how to deal with and translate the public policy changes. MAJOR HEALTH POLICY ISSUES AFFECTING THE ELDERLY The impact of prospective payment on quality. Recent legislation has improved monitoring and patient's rights (such as appeal nghts), peer review organization (PRO) monitoring, and discharge planning require- ments and has prompted study of severity of illness. However, many concerns remain. We need to have a long-tenn commitment to demon- stration project research, particularly in the area of determining quality of care. We need longitudinal studies of patient care to determine the functional status of patients at the time of discharge, and we need to monitor patients over a long period to find out whether early discharge actuary ends up costing more than if the patients had stayed in the hospital longer. We need to address the issue of meaningful outcome measures. We need better collection and use of PRO date multiple data bases that go beyond the Medicare Part A data bases. Finally, we need improved consumer and physician knowledge of the payment system. How do we correct misinformation? How do we better educate people about how the system works? With the new empha- sis on capitated care, what are the implications of some of the incentives in the system to save money and the implications on quality of care? Physician payment. The local-level debates tend to focus on whether Congress should mandate that physicians accept Medicare as- signment. ~ have been an advocate on behalf of He elderly for a long time, and it is very difficult to say whether mandating assignment is good. 133

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134 STEPHEN R. McCONNELL But, you cannot ignore the many inequities built in to reimbursement, and Hose provide incentives. What message does this send to physicians? If we require physicians to accept assignment without addressing He inequi- ties, then we simply pile problems on top of problems. Because physicians control about 70 percent of He total heady care spending, of which beneficiaries are paying 60 percent of the total physician charges, He payment issue becomes critical from the physi- cian's point of view and fiom the consumer's point of view. How do we place -controls on cost of Past B and on physicians without limiting innovation and access to care? There are relative value scales. There are many unanswered questions about how to implement and reward cogn~- tive services, but the approach is very important and ~ hope Hat we continue along these lines. Although it is a short-term step toward controlling costs, how do we reduce overpriced procedures? Which procedures are overpriced? What implications will controlling costs have on the quality of care? One argument that physicians make is that doctors do not charge Heir poor patients for the excess birding, and so if we mandate assignment, we are subsidizing the wealthier patients. Arguments on He over side are equally important. ~~~~-- ~~ ' ~ ~ ~~ variations: Is less better? We need to develop a consensus on styles of practice without limiting innovation. life-sustaining technology. The Office of Technology Assess- ment (OTA) released a good report recently on the issue of life-susta~ning technology and the relevance of age. The OTA will meet again to decide whether some congressional public policy steps should be taken. One of the OTA study's more important findings was that age is a very poor predictor of outcome. We must continue research to find better indicators of functional status. One of the first things ~ did when ~ came to Congress to work for Claude Pepper was to study the issue of retirement at age 60 among pilots. The Institute of Medicine and the National Institute on Aging were also involved in that study. The conclusion, after several years of work, was mat age is a very bad predictor. No dramatic, precipitous drop in perform- ance ability is demonstrated at age 60, but we could not come up with a better age. This dilemma reflects many of our public policy concerns. How do we make decisions about access to technology on criteria other than age? When the study was released the point was made that one does tonally, there is me question of medical practice

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ACUTE HOSPITAL CARE: RESEARCH AND POLICY ISSUES 135 not know if a 75-year-old man who has heart problems, chronic arthritis, and a number of over ailments is in a nursing home or siding on the Supreme Court Post-hospital care. ~ now spend a good deal of my time trying to get the issue of long-term care on the presidential agenda. We cannot start debating the fine points of these problems until we get the policymakers at least to acknowledge that something must be done. The focus now, however, on post-hospital care, particularly in the area of long-term care, has been more on quality of care than on access to care.