DRG Payment for Long-term Ventilator Patients— Revisited
Nearly a year ago, we analyzed the cost and payment of long-term ventilator-dependent Medicare patients and concluded that a financial bias against such patients existed in the Diagnostic Related Groups (DRG) system. We analyzed 95 long-term ventilator-dependent Medicare patients, defined as those who received three or more days of continuous ventilator treatment and spent no time in surgical intensive care. Surgical intensive care patients were excluded in the interest of focusing on patients who received ventilator care because of a chronic respiratory problem or respiratory complication of a medical illness, rather than as an aid in recovery from surgery. Payment for the 95 patients was calculated to be $2.2 million below cost, representing an average loss per case of $23,129.
In our original article, we recommended three ways of recognizing the cost of care for long-term ventilator-dependent patients in the DRG system in order to alleviate the systems financial bias. These were as follow: (1) to make ventilator treatment a determining factor in DRG assignment; (2) to provide an exemption from DRG prospective payment for hospitals with dedicated respiratory care units; and (3) to provide a DRG payment adjustment for long-term ventilator-dependent patients in the form of a per diem or percentage add-on payment to the DRG rate based on the duration of the ventilator treatment. buy yasmin online
Since the results of our analysis were presented in March 1987, the Health Care Financing Administration (HCFA) has created two new DRGs to help recognize the higher costs of patients who require mechanical ventilation. The new DRGs, which became effective on Oct 1,1987, encompass patients with a principal diagnosis in Major Diagnostic Category (MDC) 4, Respiratory Diseases and Disorders which require mechanical ventilation.
The two DRGs differentiate patients based on whether or not a tracheostomy was performed. Patients ventilated through a tracheostomy are assigned to DRG 474, Respiratory System Diagnosis with Tracheostomy, and patients ventilated through endotracheal intubation are assigned to DRG 475, Respiratory System Diagnosis with Ventilator Support. DRG 474 is ordered above all other DRGs in MDC 4 including the surgical ones. DRG 475 is a medical DRG intended to recognize the resources associated with mechanical ventilation of nonsurgical patients. The weighting factors for these DRGs are 11.8772 for DRG 474 and 3.175 for DRG 475, meaning that payment for patients assigned to these DRGs is respectively 12 and three times greater than for the average Medicare patient.