How Is “Prospective Payment for Hospital Services” Linked to an Ethical Issue ?

Question by paladin: How is “prospective payment for hospital services” linked to an ethical issue ?
it has been asserted that “HCFA began prospective payment for hospital services, and thus the ethical issue of futility was born”

Best answer:

Answer by etpilot
After the institution of PPS, Part B Medicare patients receive far less therapy than they did under the previous Medicare guidelines, and more are permanently placed in nursing homes because they don’t get all the therapy they need in order to function at home.
The patient’s diagnosis determines the number of rehab minutes the patient is entitled to. For a hypothetical example, a patient who had a stroke is eligible for 90 minutes of therapy par day, regardless of complications (such as a swallowing disorder). Those 90 minutes are divided (not evenly) among physical, occupational, and speech therapy. The assignment of minutes is arbitrary and determined by the rehab director (usually a PT). In my experience, PT gets most of the minutes and works toward ambulation. For some inexplicable reason, a patient who has a feeding tube and has a good prognosis for eventual oral feeding gets fewer ST minutes than the PT does (usually about 25 min.). I know I’d rather eat than walk!
Part B reimbursement limits $ 1500 for PT, and $ 1500 divided by OT and ST. I don’t know the current status of these limits. Prior to PPS, each discipline provided an hour of therapy. Many more patients were able to be discharged either to home or a senior group home and had no skilled needs.
Befor the institution of PPS, I was the director of ST in two nursing homes and had a staff of seven therapists. When PPS was instituted, I had to let five of them go. Physical therapy did not have a reduction in staff, nor did OT. I also took a 50% pay cut, as did my other two therapists. We also worked fewer hours, and fewer patients were weaned off of tube feeding and onto oral feeding, as our minute limit was 20 minutes! Just try to rehabilitate a swallowing disorder in 20 minutes per day. God forbid these patients had a communicative disorder; they never got the therapy to learn how to communicate again because of the PPS limit.
I think you may have an idea of the ethical and cost issues involved by now. So it’s more important to walk again than to eat by mouth and/or communicate one’s basic needs. Also, it is MUCH more expensive for Medicaid to take care of a nursing home patient (and most of these unrehabilitated patients end up on Medicaid) than if they go home. Go figure! Needless to say, I am no longer practicing.


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