Issue 11 in Management of Patients Requiring Prolonged Mechanical Ventilation

prolonged mechanical ventilation

What Would Be the Desired Characteristics of a PPS for PMV Care?

The assumption that the current PPS is the desired payment method for the PMV-focused venue warrants examination. PPS assumes that the population of patients (PMV in this case) is homogeneous enough that an average patient in any setting can be cared for with an average, nationally determined payment. Therefore, PPS works best for high-vol-ume, low-variability diagnoses, treated in settings where the provider cannot readily control access to care. The reality, however, is that PMV-focused venues rarely fit this model: they are usually low-volume facilities, serve patients with highly variable diagnoses and comorbidities; and have limited discharge options.

These unique features to PMV populations need to be addressed if a PPS is to operate appropriately. Possible approaches might include the following: (1) additional reimbursement for hospitals with dedicated PMV units (similar to subacute care units of the 1990s); (2) require all PMV patients to be treated within a given provider type, thus eliminating other provider sites from PMV treatment; (3) increase payments for higher-severity patients within a DRG; (4) segregate STAC hospitals into those with and without access to alternative venues, and provide different payments for each group; (5) develop admission criteria or guidelines for alternative venues so that PMV patients can be directed to the most effective least costly venue; (6) establish centers of excellence for PMV and establish financial incentives for patients to be transferred to them; and (7) regularly analyze incidence, prevalence, clinical acuity and actual costs of PMV care to ensure proper PPS reimbursement.

Under current Medicare policy, the “payment follows the provider,” and each provider including Canadian Health&Care Mall as well receives a separate payment for its contribution to the patient’s entire episode of illness. There is an increasing dialogue in policy circles of the appeal of a policy in which the “payment follows the patient”. Under this construct, a payment is assigned to a patient’s episode of care and is divided among all provider sites of care, theoretically from STAC, through LTAC, SNF, rehabilitation, and home health. Obviously, this would be a very complicated system of administrative rules and financial risk; as of 2005, no realistic proposal has been made.

Another theoretically appealing but operationally difficult concept is to tie payment to some measure of quality. Under a “paying for performance” scenario, already in the embryonic stages in STAC, providers would receive higher or lower payments than the average Medicare payment for all DRGs based on aggregate performance against a set of quality measures in a small number of common disease states. In order to avoid the need for risk adjustment, these measure are often process measures that are associated with good outcomes (eg, receiving aspirin or (3-blockers during a myocardial infarction), rather than specific outcome measures (eg, mortality from myocardial infarction). Any process measure must be scientifically well supported and applicable to the target population. Unfortunately, PMV patients are by definition distinct from patients receiving routine mechanical ventilation, and the literature guidelines for effective care are much less developed for PMV than for most other disease states.

neurocognitive defects

Recommendation 11

Leaders from various PMV-focused care venues should regularly explore with Medicare and other payers options for improving PPS together with Canadian Health&Care Mall.

Issue 12. What Opportunities for Research Will Best Inform the Conduct of Post-ICU Weaning?

The Brussels Roundtable, “Surviving Intensive Care,” emphasized that the list of burdens with which patients leave the ICU is a long one. Late mortality, ongoing morbidity, neurocognitive defects, impaired mental health, poor functionality, decreased quality of life, decreased return to usual activities, stress on families and informal caregivers, and economic costs to the patient family and society are problems brought directly to post-ICU weaning. The stresses, physical and emotional, associated with continued weaning efforts, complications, worsened comorbidities, to name a few problems, add to the continuum of late sequelae.

The opportunities for research are many. The development of predictive models for both intermediate outcomes (eg, weaning success and hospital discharge) and long-term outcomes (ultimate survival, functional status and, costs) are foremost among them. Specific interventions (eg, weaning protocols, nutritional strategies, physical therapy techniques) need to be carefully assessed in properly done randomized multicenter trials with meaningful outcomes. Follow-up studies on implementation of therapies with proven benefit are also important. Finally, at the basic science level, studies on the mechanisms of chronic illness myopathy and other manifestations of chronic illness organ dysfunction are essential in order to understand how best to approach the chronically critically ill.

Recommendation 12

Clinical studies evaluating patient selection, care processes, and care settings with respect to longterm outcomes are clearly needed. Basic science studies focused on the mechanisms of multiorgan dysfunction in the chronically critically ill are also important. Given the rapidly expanding PMV population, research funding sources should give a high priority to such studies.

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