Explicit Rationing
Provision of ICU care can involve both explicit and implicit forms of rationing. Explicit ration- ing of medical care generally involves direct ad- ministrative decisions on such issues as exclusion of certain types of services from insurance cov- erage, limitations on the availability of specific methods of care, preauthorized and concurrent review and approval for expensive treatments and
procedures, required intervals between provision of specified services, and limitations on total benefits (159). In the context of the ICU, explicit rationing might include the establishment of med- ical criteria for treatment based on predictors of outcome for ICU care as they become available.
In addition to predominately medical considera- tions, factors such as life expectancy, family role, and social contribution could also be formally considered (196), although the experience of al-
Ch. 8—Foregoing Life-Sustaining Treatment ● 73
locating rare renal dialysis machines and selecting patients for kidney transplants in the 1960s on the basis of social factors was nearly intolerable to those involved (2,14) and might not be accept- able to society.
The ethical considerations of how to decide who should receive lifesaving treatment and who should not has received attention by bioethicists (13). It is relevant here to note that to avoid ex- plicit rationing for lifesaving treatments, health planners and policymakers have tended either to approve facilities or financing mechanisms that will assure treatment for nearly everyone with a particular illness, e.g. end-stage renal disease, or they make a decision not to facilitate treatment for anyone suffering from a certain condition, e.g.
patients needing heart transplants (111) except perhaps on an experimental basis (122). Since ICUs are not disease-specific, explicit rationing on the basis of disease would not seem to be an appropriate means of limiting ICU care.
Explicit rationing of ICU care might also include limits on covered benefits beyond a certain amount, or in certain clinical situations, where patients could have to bear the costs of ICU care directly.
Currently, most patients have insurance cover- age for most ICU costs. Many without coverage have been subsidized. In public hospitals, ration- ing of limited ICU beds has been based largely on a combination of medical factors, such as likelihood of successful intervention, and demo- graphic factors, such as age, and not on considera- tions of ability to pay (186). There is the real ques- tion of whether society would tolerate explicit denial of “life and death” ICU care on the basis of insurance coverage or personal wealth. In re- cent years, Congress has considered several pro- posals for national health insurance that would extend coverage to everyone for catastrophic ill- ness in order to avoid denial of care on the one hand and the possibility of extreme financial hard- ship and bankruptcy on the other (72).
Implicit Rationing
Implicit rationing involves limitations on the resources available to health care providers, such as fixed budgets and restrictions on sites of care or hospital beds (159). These limitations are im-
plicit because they do not specify what services should be provided to whom or what assessments physicians should make. Instead, they achieve their effect by placing greater pressures on phy- sicians and hospitals to make hard allocation choices. Simple reliance on the price mechanism can also be a rationing device, since everyone’s ability to pay is limited at some point; for almost all resources in our society, price does “ration”
access to goods and services. Cost-based payment for insured medical services has been a notable exception. The new DRG payment system for Medicare is a form of implicit rationing since the total payments allowed under the system are fixed, regardless of the level of services provided.
Other forms of payment limits could also re- quire rationing. Indeed, because many people lack insurance altogether or have less than full-cost, open-ended coverage, implicit rationing occurs for many medical services today, particularly non- hospital care. It would be possible to limit total social spending on ICUs (or anything else) through the implicit rationing device of patient cost-shar- ing, which does not require administrative deci- sions. Such price-based allocation of resources can be troublesome, however, when applied to cata- strophic medical care for a variety of reasons (see 111).
The cost of care for the sickest patients in the ICU is currently being subsidized to a great ex- tent by those who are not as ill, and by the hos- pital. DRG fixed payments, which are not ad- justed according to the severity of the illness, will often make high-cost Medicare ICU patients sig- nificant financial “losers” for the hospital. In this situation, physicians will likely feel institutional pressures not only to alter the style of ICU care they provide to reduce costs, but also to recon- sider the thresholds for withholding and with- drawing ICU care from specific individuals. In ad- dition, hospitals may limit or even reduce the number of ICU beds, thus reducing access for pa- tients who would have received higher cost ICU care. This form of implicit rationing of ICU care raises a number of questions:
● What protections will patients require to avoid arbitrary decisionmaking to limit care?
Will certain categories of patients, such as the elderly, the retarded, or otherwise chronically
74 ● Health Case Study 28:: ]ntensive Care Units: Costs, Outcome, and Decisionmaking
●
●
dependent persons who might benefit from ICU care, be systematically excluded on purely economic considerations?
Will the potential threats of criminal prosecu- tion and malpractice suits act as a sufficient countervailing force to the new incentives that DRGs will bring? More specifically, will there be a fundamental conflict between traditional malpractice standards and new norms of practice that may involve limiting care more strictly? Malpractice law has tradi- tionally judged the behavior of medical care providers almost exclusively by the custom- ary practice of their peers, rather than by an independently determined standard of so- cially appropriate care (22). Malpractice law generally does not recognize varying styles of care to suit varying available resources.
It remains to be seen whether courts will rec- ognize limited available resources as a fac- tor in determining negligence. In fact, hos- pitals and physicians may have new incentives not to treat very sick ICU-type patients in the first place, not only because of the di- rectly negative economic consequences, but also because it may place them in legal jeop- ardy under existing malpractice standards.
Once care has been initiated, the primary responsibility of the provider is to meet a high standard of care that may not be reim- bursed sufficiently under the DRG payment scheme. Hospitals may decide systematically to avoid the responsibility in the first place by diverting and transferring patients elsewhere.
Will society tolerate different levels of ICU care based on willingness and ability to pay?
Medicare will prohibit hospitals for the most part from seeking direct payments from its patients above the allowable DRG payments
(Social Security Act Amendments of 1983, Public Law 98-21). Can a Medicare patient in a life or death situation be denied the con- tinued ICU care he or she desires and is will- ing to pay for personally, primarily through private insurance, because Medicare pro- hibits patient payments above the DRG limit? If not, it is likely that different types of ICUs will develop, based largely on the ability to pay.
● Finally, what procedures should be used to assist ICU decisionmaking in an era in which at least some patients become financial
“losers” for the hospital? A number of pro- cedural safeguards have been proposed to protect the interest of patients who have in- sufficient capacity to make particular deci- sions on their own behalf, including: 1) nam- ing an appropriate surrogate to act on the patient’s wishes or in the patient’s interest;
2) establishing administrative arrangements, such as ethics committees for review and con- sultation of different decisions; and 3) per- mitting advance directives, such as living wills, through which people designate so- meone to make health care decisions on their behalf, and/or give instructions about their care (191). While initially proposed in the context of protecting the interests of in- competent patients, these or other procedural safeguards also appear necessary to protect the interests of competent patients who might otherwise be rationed out of the ICU. ICU decisionmaking has been difficult when there was no theoretical conflict between the in- terests of patient, physician, and institution.
Under a prospective payment system, patients, physicians, and hospitals may have different interests.
9❑
Conclusions and Possible Future Steps
9
Conclusions and Possible Future Step;
Until passage of the Social Security Act Amend- ments of 1983 (Public Law 98-21), intensive care unit (ICU) expansion was able to proceed with- out major consideration of costs because of the favorable payment environment. Indeed, tight- ened section 223 limits on costs of routine hospi- tal beds in 1979 and 1980 may have even stimu- lated ICU expansion. It would seem clear that Medicare’s inpatient hospital prospective diagno- sis-related group (DRG) payment system will cause hospital administrators and ICU directors to look differently at the costs of ICU care. Un- fortunately, they will find no easy solutions to the cost problem, particularly if Medicare allows only relatively low rates of annual spending in- creases.
Under DRG payment, some savings may be generated by better organization and management of ICUs, perhaps by centralizing separate ICUs into larger, more general ICUs (212). Arguably, additional savings may be gained by substituting lower paid health personnel for nurses or physi- cians to provide certain ICU functions (162,212).
There may be new efforts to find cost-saving tech- nologies that can substitute for expensive ICU labor. One ICU, for example, has demonstrated a significantly decreased ICU length of stay, at- tributable in part to the use of computer-assisted decision algorithms (227).
In addition, it maybe possible in the near future to predict more accurately which monitored pa- tients do not need to be in the ICU at all. In- termediate care units or other arrangements could be developed to care for these patients, probably, at a s o m e w h a t l o w e r c o s t ( 1 4 1 ) .
At the same time, however, it is now being rec- ognized that some ICU patients are discharged prematurely from the ICU. One can argue that longer stays in the ICU for these patients would not only represent a more appropriate use of the ICU but also might even save the hospital money by reducing the costs of subsequently treating for these prematurely discharged patients (246).
Nevertheless, the fact remains that relatively few ICU patients are responsible for a substan- tial portion of ICU costs. This case study has at- tempted to demonstrate the clinical, moral, legal, and economic factors which currently make it dif- ficult to decide not to treat even those patients who show little promise of benefiting from ICU care. The high-cost subgroup is spread among all ages, diagnostic groups, and disability classes (40).
There are as yet no demographic identifiers or ac- cepted general prognostic indicators which per- mit systematic exclusion of any of the high-cost group from ICU care. Public programs, private insurers, perhaps the public at large, but almost certainly hospital managers and providers, will face increasingly difficult decisions about who should be given ICU care and in what manner.
The process of ICU decisionmaking will become even more important when economics may dic- tate curtailing or even denying care to seriously ill patients.
A number of steps might improve the environ- ment for intensive care decisionmaking:
Research on developing accurate predictors of survival for patients with acute and chronic illnesses could be expanded in order to permit better informed decisions based on the likelihood of short- and long-term sur- vival. Since the results of outcome data will always be incomplete and subject to differ- ing interpretations, especially in relation to an individual patient, hospitals might con- sider formalizing an institutional “prognosis committee” whose function would be to ad- vise physicians, families, and patients on the likely survival with ICU care in individual situations. Such a committee or hospital function, perhaps utilizing a routinely up- dated national data base, obviously could also provide a similar function for non-ICU patients.
The suitability of the current DRG method of payment for ICUs should be tested. If, in fact, the DRG scheme takes insufficient ac-
77
7$ ● Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking
●
●
●
count of severity of illness, it is likely that some hospitals and, consequently, some ICU patients may face a degree of rationing that Congress did not envision.
The legal system, including legislators and the courts, may need to recognize the possi- ble conflict between malpractice standards which assume quality of care that meets na- tional expert criteria, and a decisionmaking environment in which resources may be se- verely limited. At the same time, it must be kept in mind that the threat of both malprac- tice suits and criminal prosecution may become an even more important protection against arbitrary or unfair denial and ter- mination of ICU care.
Health professionals who are involved in making decisions regarding critically ill pa- tients might benefit from more education on medical ethics and relevant legal procedures and obligations. In recent years, the journal Critical Care Medicine, published by the Society of Critical Care Medicine, has in- cluded articles and editorials on specific ethi- cal and legal issues. Likewise, new textbooks on critical care medicine (224) have devoted chapters to specific ethical and legal issues that frequently arise in the ICU. More for- mal education at the graduate and postgrad- uate level for all health professionals who work with critically ill patients might be con- sidered.
The actual decisionmaking process for criti- cally ill patients may need greater attention.
At a time when the interests of the ICU pa- tient, physician, and hospital were theoreti- cally the same, i.e., under a full-cost reim- bursement system, the need for formal rules and procedures for life and death decisions might not have been necessary. Even so, many hospitals found the need to establish formal procedures for “Do Not Resuscitate”
orders. With a payment system that sets the interests of at least some very sick ICU pa- tients against the immediate financial inter- ests of the hospital, however, it may be necessary to impose additional formal pro- tections on the decisionmaking process. Hos- pitals might explore formalizing decision- making committees or mandating second opinions to lessen the burden on individuals faced with excruciatingly difficult choices about terminating life-support. Hospitals could consider formally separating the ICU triage function from the direct patient care function, particularly with regard to the ICU Medical Director, in order to minimize po- tential conflicts of interest. More generally, society will need to decide how it wishes con- flicts over decisions on terminating life- support to be resolved—in courts, through formal hospital committees such as ethics committees, through government-imposed utilization review procedures which can fol- low fixed rules and-regulations, or other, haps more decentralized, mechanisms.
per-
Appendixes
Appendix Am—Acknowledgments and Health Program Advisory Committee