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OCR for page 132
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-
tings—settings that we have termed the "no care zone."
~32
OCR for page 133
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
OCR for page 134
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.
Representative terms from entire chapter:
functional status
