The philosophy that
comprehensive, quality health care should be provided for all citizens prompted
governmental concern about spiraling health care costs and wide variations in
charges among providers. These concerns led to the Medicare prospective payment
system (PPS) and the use of diagnosis-related groups (DRGs).
In 1983, the U.S.
Congress passed the most significant health legislation since the Medicare
program was enacted in 1965. The government was no longer able to afford to
reimburse hospitals for patient care that was delivered without any defined
limits or costs. Therefore, it approved a PPS for hospital inpatient services.
This system of reimbursement, based on DRGs, set the rates for Medicare
payments for hospital services. Hospitals receive pay-ment at a fixed rate for
patients with diagnoses that fall into a spe-cific DRG. A fixed payment has
been predetermined for more than 470 possible diagnostic categories, covering
the majority of medical diagnoses of all patients admitted to the hospital.
Hos-pitals receive the same payment for every patient with a given di-agnosis
or DRG. If the cost of the patient’s care is lower than the payment, the hospital
gains a profit; if the cost is higher, the hos-pital incurs a loss. As a
result, hospitals now place greater em-phasis on reducing costs, utilization of
services, and length of patient stay.
In addition, the
Balanced Budget Act of 1997 added new rate requirements for ambulatory payment
classifications (APCs) to hospitals and other providers of ambulatory care
services. These providers must evaluate all services provided with greater
efforts toward cost-effectiveness and reduction of costs.
To qualify for Medicare
reimbursement, care providers and hospitals must contract with peer review
organizations (PROs) to perform quality and utilization review. The PROs
monitor admis-sion patterns, lengths of stay, transfers, and the quality of
services and validate the DRG coding. The DRG system has provided hospitals
with an incentive to cut costs and discharge patients as quickly as possible.
Nurses in hospitals now
care for patients who are older and sicker and require more nursing services;
nurses in the commu-nity are caring for patients who have been discharged
earlier and need acute care services with high-technology and long-term care.
The importance of an effective discharge planning program, along with
utilization review and a quality improvement pro-gram, is unquestionable.
Nurses in acute care settings must as-sume responsibility with other health
care team members for maintaining quality care while facing pressures to
discharge pa-tients and decrease staffing costs. These nurses must also work
with nurses in community settings to ensure continuity of care.