Rehospitalization for identified diagnoses will decrease revenue for many hospitals. Will the specification for CMS restriction of payment affect mortality for those diagnoses when comparing previous patient outcomes (before CMS identified them)? Is there a difference in longevity of life from point of diagnosis to death in comparison to previous rates? Is there a way to identify bias toward care of those patients? I thought of this topic when I heard another physician "diagnose" a patient as having "too many birthdays." I think the hospital's pressure on physicians to reduce hospitalizations has a farther reaching impact than we can recognize. Knowing that 3 out of 3 people die anyway may change physician's perspectives of how they deliver care to patients with complicated illnesses. I have seen more jaded physicians in dealing with the pressures of reducing costs and managing patients, while taking personal pay cuts as well. Decreasing longevity of patients also has a potential savings to the CMS program as the number of the geriatric population will continue to expand with the burden of their care placed on the much fewer, younger working population.

According to http://www.census.gov/population/socdemo/statbriefs/agebrief.html "During the 20th century, the number of persons in the United States under age 65 has tripled. At the same time, the number aged 65 or over has jumped by a factor of 11! Consequently, the elderly, who comprised only 1 in every 25 Americans (3.1 million) in 1900, made up 1 in 8 (33.2 million) in 1994. Declining fertility and mortality rates also have led to a sharp rise in the median age of our Nation's population -- from 20 years old in 1860 to 34 in 1994... According to the Census Bureau's "middle series" projections, the elderly population will more than double between now and the year 2050, to 80 million. By that year, as many as 1 in 5 Americans could be elderly. Most of this growth should occur between 2010 and 2030, when the "baby boom" generation enters their elderly years. During that period, the number of elderly will grow by an average of 2.8 percent annually. By comparison, annual growth will average 1.3 percent during the preceding 20 years and 0.7 percent during the following 20 years."

Placing incentives toward providing or not providing care does not always have the desired effect. The ability to effectively manage Acute Myocardial Infarction, Heart Failure, and Pneumonia is often only available in a hospital setting. Even in other facilities (such as long term care facilities or outpatient clinics), the care is not as expedient and could adversely affect outcomes. Should the focus be more on determination of readiness for discharge and not DRGs? CMS limitations on both ends of the diagnosis greatly affects expectations in care when facilities lose monies for keeping a patient longer than typical, which decreases a hospital's revenue, or puts the patient at greater risk for rehospitalization when discharge might have been delayed if the diagnosis-related group standard payment was not also a consideration, which also decreases revenue to hospitals.

The information can be a national "eye-opener" for how the desire to streamline costs and mandating care restrictions could have a potential bad (or good) outcome. If the identification of a diagnosis within the guidelines points to an additional increase in mortality risks, given the knowledge of the advancing age of our populations and risks of these diagnoses being more likely in their future, recognizing limitations in care should be a consideration in managing the costs of healthcare. Is there really a value which should be placed on the lives of people with a complicated diagnosis, or should we develop other solutions before imposing a system which may promote mortality?

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