Rosenthal G E, Landefeld C S
Section of Clinical Epidemiology, Cleveland Veterans Affairs Medical Center, OH.
Arch Intern Med. 1993 Jan 11;153(1):89-96.
It is uncertain, under prospective payment, if hospitals face financial disincentives to treat older Medicare patients. Therefore, we studied associations between age and hospital charges and length of stay for Medicare patients and the impact on hospital reimbursement of Medicare's decision in October 1987 to eliminate older age (> or = 70 years) as a criterion for stratifying diagnosis-related groups (DRGs).
The 23,179 medical and surgical admissions to one academic medical center in 1985 through 1989 who were aged 65 years or more were studied using a retrospective cohort design. Clinical and financial data were obtained from hospital databases; charges and length of stay for each patient were adjusted for DRG weight, the measure used to determine reimbursement. Admission severity of illness was measured for 11,060 patients using the Nursing Severity Index, a previously validated method.
Compared with patients aged 65 to 69 years, DRG-adjusted charges were 1%, 5%, 5%, and 6% higher and DRG-adjusted length of stay was 4%, 11%, 16%, and 18% greater for patients aged 70 to 74 years, 75 to 79 years, 80 to 84 years and 85 years or more, respectively. In multivariate analyses, these estimates were similar, even after controlling for sex, race, socioeconomic status, and other variables associated with charges and length of stay. However, further controlling for severity of illness revealed that nearly all of the differences in charges and a large proportion of the differences in length of stay in older patients could be explained by their higher severity of illness. In separate stratified analyses, the association with age was stronger and more consistent in patients admitted after October 1987 and in medical patients.
These findings suggest that currently hospitals may face financial disincentives to care for older Medicare patients and that the equitability of DRG-based hospital payments, with respect to age, may have been adversely affected by Medicare's decision to eliminate older age (> or = 70 years) as a criterion for classifying DRGs. The inclusion of patient age in prospective payment formulas may make hospital reimbursement more equitable.
在按病种付费的情况下，医院是否会因收治老年医疗保险患者而面临经济上的不利因素尚不确定。因此，我们研究了医疗保险患者的年龄与医院收费及住院时间之间的关联，以及1987年10月医疗保险决定取消将年龄≥70岁作为诊断相关分组（DRG）分层标准对医院报销的影响。
采用回顾性队列研究设计，对1985年至1989年期间一家学术医疗中心收治的23179例年龄在65岁及以上的内科和外科住院患者进行研究。临床和财务数据来自医院数据库；对每位患者的收费和住院时间按照DRG权重进行调整，DRG权重是用于确定报销金额的指标。使用护理严重程度指数对11060例患者的入院疾病严重程度进行评估，这是一种先前已验证的方法。
与65至69岁的患者相比，70至74岁、75至79岁、80至84岁以及85岁及以上患者经DRG调整后的收费分别高出1%、5%、5%和6%，经DRG调整后的住院时间分别长4%、11%、16%和18%。在多变量分析中，即使在控制了性别、种族、社会经济地位以及其他与收费和住院时间相关的变量后，这些估计值仍相似。然而，进一步控制疾病严重程度后发现，老年患者收费方面几乎所有的差异以及住院时间差异的很大一部分都可以由他们更高的疾病严重程度来解释。在单独的分层分析中，1987年10月之后入院的患者以及内科患者中，年龄与收费和住院时间的关联更强且更一致。
这些发现表明，目前医院可能因照顾老年医疗保险患者而面临经济上的不利因素，并且基于DRG支付医院费用在年龄方面的公平性可能受到医疗保险取消将年龄≥70岁作为DRG分类标准这一决定的不利影响。将患者年龄纳入按病种付费公式中可能会使医院报销更加公平。
