Hospitalization: The Changing Focus
Not so long ago, having a heart attack meant staying in the hospital for six weeks. Now a patient with a routine heart attack may be out of the hospital in less than five days. Is this good care? Are patients being discharged for financial reasons?
In 1981, the average Medicare patient stayed in the hospital an average of almost 10 1/2 days. Ten years later, the average stay was 8 1/2 days. Today, Medicare patients in many hospitals have a stay of less than 5 days. How did this come to pass? In 1982, it became clear that a large part of Medicare costs was being spent on hospital care. In an attempt to reduce the growth of these costs, the government initiated Diagnosis-Related Groups, or "DRGs". This system gave the hospital a fixed fee for each hospital admission, encouraging the hospital itself to discharge patients sooner, so as to save money. There was no incentive for physicians to discharge patients sooner, but you can be sure that the hospitals did what they could to encourage doctors to send patients home sooner. Today, with the advent of managed care and health maintenance organizations (HMOs), there are new incentives to reduce hospital stays and costs. And some of these savings benefit the physicians, as well.
What does this mean for patient care? One would first think that incentives to reduce hospital stays might have a negative impact on patient care. This is often not the case. For example, the heart attack patient who now is discharged from the hospital after just five days is put into a cardiac rehabilitation program. Generally, for most conditions, prolonged bed rest is detrimental for patients. In fact, hospitals are often not safe places for patients: hospital inpatients are at risk for developing infections or having bad reactions to medications.
As a geriatrician, I tell my patients that I will try very hard to keep them out of the hospital. If they do need to be hospitalized, I will do everything I can to get them out as quickly as possible. Do I say this in order to save Medicare’s money? No. This practice, plain and simple, is just good geriatric medicine. Patients do better in their own homes than anywhere else. The development of excellent home health care programs has allowed for much more medical care to be delivered in the patient's own home. This often works out as the best way to be treated for a medical condition.
There is no evidence that shortened hospital stays have lowered the quality of healthccare. In fact, as noted above, it is quite possible that reduced stays in the hospital may in fact improve the quality of care. A focus on health prevention, which tries to keep people out of the hospital by keeping them healthy, makes a lot of sense. An aggressive approach to treatment as an outpatient in a doctors office or at home which tries to keep people out of the hospital by getting them well also makes sense. Moving a patient into a rehabilitation program quickly from a hospital stay in order to prevent muscle weakness and debility is often the right thing to do. A geriatric medical care approach, which tries to reduce time in the hospital, can be quite beneficial if the approach is good medical care rather than just trying to save money.